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Wienhold J, Rayatdoost F, Schöchl H, Grottke O. Antidote vs. unspecific hemostatic agents for the management of direct oral anticoagulant-related bleeding in trauma. Curr Opin Anaesthesiol 2024; 37:101-109. [PMID: 38390922 DOI: 10.1097/aco.0000000000001349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The advent of direct oral anticoagulants (DOACs) marks a significant milestone in anticoagulant treatment. However, DOACs can exacerbate bleeding, which is challenging for the treating clinician, especially when combined with traumatic injury. RECENT FINDINGS In major bleeding associated with DOACs, rapid reversal of the anticoagulant effects is crucial. Recent observational and nonrandomized interventional trials have demonstrated the effectiveness of the specific antidotes andexanet alfa and idarucizumab as well as the unspecific prothrombin complex concentrates (PCCs) to counteract the anticoagulant effects of DOACs. The European Society of Anaesthesiology and Intensive Care guideline for severe perioperative bleeding and the European trauma guideline propose divergent recommendations for the use of andexanet alfa and PCC to obtain hemostasis in Factor Xa inhibitor-related bleeding. The conflicting recommendations are due to limited evidence from clinical studies and the potential increased risk of thromboembolic complications after the administration of andexanet. Regarding dabigatran-associated major bleeding, both guidelines recommend the specific reversal agent idarucizumab as first-line therapy. SUMMARY Current guidelines recommend specific antidots and PCCs in DOAC-related major bleeding. Prospective randomized trials comparing specific vs. nonspecific hemostatic agents in the perioperative setting are needed to evaluate the effectiveness and safety of the hemostatic agents.
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Affiliation(s)
- Jan Wienhold
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Farahnaz Rayatdoost
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, Vienna, Austria
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
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2
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Lee S, Ross JA, Zalpour A, Henry JT, Rojas Hernandez CM. Management of DOAC-related bleeding in cancer patients: a single center-case series. J Thromb Thrombolysis 2024; 57:677-682. [PMID: 38556578 DOI: 10.1007/s11239-024-02962-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2024] [Indexed: 04/02/2024]
Abstract
Venous thromboembolism (VTE) and stroke carry significant mortality and morbidity in cancer patients. Direct oral anticoagulants (DOACs) have been demonstrated to be effective for the treatment of VTE and prevention of stroke in atrial fibrillation (AF). Bleeding rates are variable and are based on the cancer type and the patient's specific risk factors. There are approved specific antidotes for DOAC-associated bleeding. Other strategies are available for bleeding reversal, including the use of prothrombin complex concentrate (PCC). No randomized studies have compared head-to-head the efficacy and safety of reversal agents. We aim to examine the safety and effectiveness of hemostatic agents in cancer patients with DOAC-related major bleeding. A retrospective chart review study of patients at MD Anderson Cancer Center with DOAC-related major bleeding between 2014 and 2019. Bleeding severity and clinical hemostasis were described based on ISTH guidelines and the Sarode criteria, respectively. The rates of thrombotic complications and mortality at 30-day from the index bleeding event were described. We identified 23 patients with DOAC-related major bleeding; 14 patients received PCC and 9 patients received andexanet alfa. The most common sites of bleeding were the gastrointestinal tract and intracranial. Effective hemostasis and 30-day mortality were similar to reported results from other reports of outcomes of reversal agents for DOAC related-bleeding in non-cancer patients. One patient in each treatment group experienced a thrombotic event. Further larger scale studies are needed to confirm our findings in cancer patients.
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Affiliation(s)
- Sophia Lee
- The University of Texas Long School of Medicine, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Jeremy A Ross
- The Center for Cancer and Blood Disorders, 800 West Magnolia Avenue, Fort Worth, TX, 76104, USA
| | - Ali Zalpour
- The University of Texas MD Anderson Cancer Center, Pharmacy Clinical Programs, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Jason T Henry
- Sarah Cannon Research Institute at HealthOne, Denver, USA
| | - Cristhiam M Rojas Hernandez
- The University of Texas MD Anderson Cancer Center, Section of Benign Hematology, 1515 Holcombe Blvd. Unit 1464, Houston, TX, 77030, USA.
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Sheikh-Taha M, Clark HL, Crawley RM. Efficacy and Safety of Activated Prothrombin Complex Concentrate for Reversal of the Anticoagulant Effect of Apixaban and Rivaroxaban in Patients with Major Bleeding. Clin Drug Investig 2023; 43:883-888. [PMID: 37882941 DOI: 10.1007/s40261-023-01316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The use of activated prothrombin complex concentrate (aPCC) to treat direct oral anticoagulant (DOAC)-associated bleeding is off-label and clinical experience is limited. OBJECTIVES We aimed to assess the efficacy and safety of aPCC in reversing the anticoagulant effect of apixaban and rivaroxaban in patients presenting with major bleeding. METHODS A retrospective cohort study of adult non-randomized patients was conducted at a tertiary referral medical center in the United States (US) to investigate the use of aPCC for the reversal of the anticoagulant effect of apixaban and rivaroxaban in patients presenting with major bleeding. The primary outcome was achieving clinical hemostasis according to prespecified criteria. Safety outcomes included the occurrence of thrombotic events during hospitalization. RESULTS A total of 217 patients were included in the study. Intracranial hemorrhage (ICH) was the most common site of bleeding (n = 100, 46.1%), followed by gastrointestinal bleed (n = 87, 40.1%). Clinical hemostasis was achieved in 170 patients (78.3%), and the risk of not achieving hemostasis with ICH-related bleeding was significantly higher than that of non-ICH-related bleeding (2.5, 95% confidence interval [CI] 1.44-4.34; p < 0.001). Eight patients not achieving hemostasis died during hospitalization, all of whom were suffering from ICH, and mortality associated with non-ICH-related bleeding was significantly lower compared with ICH-related bleeding (0.91, 95% CI 0.86-0.97; p < 0.001). Thromboembolic events during hospitalization occurred in one patient (0.5%). CONCLUSIONS The use of aPCC for the management of apixaban- or rivaroxaban-related major bleeding is effective in most cases and is associated with a low risk of thromboembolism.
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Affiliation(s)
- Marwan Sheikh-Taha
- Department of Pharmacy Practice, Lebanese American University, PO Box 36, Byblos, Lebanon.
- Department of Pharmacy, Huntsville Hospital, Huntsville, AL, USA.
| | - Holly L Clark
- Department of Pharmacy, Huntsville Hospital, Huntsville, AL, USA
| | - R Monroe Crawley
- Department of Pharmacy, Huntsville Hospital, Huntsville, AL, USA
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Rodriguez V, Stanek J, Kerlin BA, Dunn AL. Andexanet Alfa Versus Prothrombin Complex Concentrates/Blood Products as Apixaban/Rivaroxaban Reversal Agents: A Survey Among Pediatric Hematologists. Clin Appl Thromb Hemost 2022; 28:10760296221078842. [PMID: 35275498 PMCID: PMC8921759 DOI: 10.1177/10760296221078842] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Direct oral factor Xa inhibitors (DXIs) are approved for use in adult patients with non-valvular heart disease for stroke prevention, and the treatment/prevention of venous thromboembolism (VTE). Recent pediatric clinical trials have demonstrated safety and efficacy of direct oral anticoagulants (DOACs) in the treatment of VTE. However, there is a lack of evidence regarding the use of andexanet alfa and prothrombin complex concentrates (PCC) for anticoagulation reversal of DXIs in the pediatric population. To better understand current DXI reversal strategies in this age group, a 10-question survey was conducted among pediatric hematology members of the Hemostasis and Thrombosis Research Society. Seventeen percent completed the survey (27 of 163 pediatric hematology members) with 74% (n = 20) reporting their use of DXIs for the treatment and prevention of VTE. Forty-four percent (n = 12) would choose andexanet alfa as first-line treatment for life-threatening bleeding while 52% (n = 14) would use PCC first with one individual choosing recombinant factor VII for DXI reversal. Clinical studies of andexanet alfa and PCC for the management of DXI-associated life-threatening bleeding require further investigation in the pediatric population.
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Affiliation(s)
- Vilmarie Rodriguez
- Division of Hematology/Oncology/Blood and Marrow Transplantation, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph Stanek
- Division of Hematology/Oncology/Blood and Marrow Transplantation, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH, USA
| | - Bryce A Kerlin
- Division of Hematology/Oncology/Blood and Marrow Transplantation, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.,Center for Clinical and Translational Research, The Abigail Wexner Research Institute, Columbus, OH, USA
| | - Amy L Dunn
- Division of Hematology/Oncology/Blood and Marrow Transplantation, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Yorkgitis BK, Tatum DM, Taghavi S, Schroeppel TJ, Noorbakhsh MR, Philps FH, Bugaev N, Mukherjee K, Bellora M, Ong AW, Ratnasekera A, Nordham KD, Carrick MM, Haan JM, Lightwine KL, Lottenberg L, Borrego R, Cullinane DC, Berne JD, Rodriguez Mederos D, Hayward TZ, Kerwin AJ, Crandall M. Eastern Association for the Surgery of Trauma Multicenter Trial: Comparison of pre-injury antithrombotic use and reversal strategies among severe traumatic brain injury patients. J Trauma Acute Care Surg 2022; 92:88-92. [PMID: 34570064 DOI: 10.1097/ta.0000000000003421] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients. METHODS An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality. RESULTS Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77). CONCLUSION Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk. LEVEL OF EVIDENCE Prognostic, level II.
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Affiliation(s)
- Brian K Yorkgitis
- From the Department of Surgery (B.K.Y., M.C., A.J.K.), University of Florida College of Medicine-Jacksonville, Jacksonville, Florida; Trauma Division (D.M.T.), Our Lady of the Lake RMC, Baton Rouge, Louisiana; Department of Surgery (S.T.), Tulane School of Medicine, New Orleans, Louisiana; Department of Surgery (T.J.S.), UC Health Memorial Hospital, Colorado Springs, Colorado; Department of Surgery (M.R.N., F.H.P.), Allegheny Health Network, Pittsburgh, Pennsylvania; Division of Trauma/Acute Care Surgery (N.B.), Tufts Medical Center, Boston, Massachusetts; Department of Surgery (K.M., M.B.), Loma Linda University Medical Center, Loma Linda, California; Department of Surgery (A.W.O.), Reading Hospital Tower Health, Reading, Pennsylvania; Department of Surgery (A.R.), Crozer Keystone Health System, Upland, Pennsylvania; Tulane University Medical School (K.D.N.), New Orleans, Louisiana; Department of Surgery (M.M.C.), Medical City Plano, Plano, Texas; Department of Surgery (J.M.H., K.L.L.), Via Christi Hospitals Wichita, Wichita, Kansas; Department of Surgery (L.L., R.B.), St. Mary's Medical Center, West Palm Beach, Florida; Department of Surgery (D.C.C.), Maine Medical Center, Portland, Maine; Department of Surgery (J.D.B., D.R.M.), Broward Health Medical Center, Fort Lauderdale, Florida; Department of Surgery (T.Z.H.), Indiana University School of Medicine, Eskenazi Health, Indianapolis, Indiana
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6
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Systemic Anticoagulation and Reversal. Surg Clin North Am 2021; 102:53-63. [PMID: 34800389 DOI: 10.1016/j.suc.2021.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
An increasing number of patients are on anticoagulation for a variety of indications. Patients on anticoagulation who present to the hospital with life-threatening hemorrhage, whether trauma related or not, must be assessed for the reversal of anticoagulation. Identification of the type of anticoagulation, the timing of the most recent usage of anticoagulation, and the efficacy of the anticoagulation all have an impact on whether reversal agents should be used. There are a variety of reversal agents, both nonspecific and specific, that could be used for reversal; however, not all reversal agents work for all anticoagulation medication. As more anticoagulation medications are used and indications expand, providers must be aware of the reversal agents available and the efficacy and indications for these reversal agents.
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7
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Falamić S, Lucijanić M, Ortner-Hadžiabdić M, Marušić S, Bačić-Vrca V. Pharmacists' interventions improve health-related quality of life of rural older person on warfarin: a randomized controlled trial. Sci Rep 2021; 11:21897. [PMID: 34754004 PMCID: PMC8578616 DOI: 10.1038/s41598-021-01394-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/21/2021] [Indexed: 12/04/2022] Open
Abstract
Warfarin therapy can significantly affect patients' quality of life and cause therapy discontinuation. This study aimed to investigate the effect of the pharmacists' interventions on the health-related quality of life (HRQoL) in older rural patients on warfarin therapy. Eligible older patients from rural area of Croatian province Slavonia were randomized into the intervention and control groups and followed for six months. Repeated education and a follow-up plan were provided to the participants in the intervention group, and if needed, the pharmacist intervened to optimize warfarin therapy. Secondary analysis on HRQoL data are presented here. Main outcome measure was Duke anticoagulation satisfactions scale questionnaire score. In total, 131 participants finished the study (median age 73 years; 51.1% male). Participants in the intervention group scored significantly lower (median being 86.5 and 66.0 in the control and intervention groups, respectively; p < 0,001), indicating higher HRQoL. Adverse drug reactions and pharmacist's intervention were identified as predictive factors for patients' HRQoL (r2 = 65.5%, P < 0.001). The study demonstrated that community pharmacist's interventions can improve HRQoL of older patients taking warfarin what is of particular significance for patients living in rural areas with less accessible healthcare and lower socio-economic status.Clinicaltrials.gov (ID: NCT03212898), 11/07/2017, retrospectively registered.
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Affiliation(s)
- Slaven Falamić
- Pharmacy Branka Marušić, Trg Ante Starčevića 24, 31450, Donji Miholjac, Croatia
| | - Marko Lucijanić
- Hematology Department, University Hospital Dubrava, Avenija Gojka Suska 6, 10000, Zagreb, Croatia
| | - Maja Ortner-Hadžiabdić
- Centre for Applied Pharmacy, Faculty of Pharmacy and Biochemistry, University of Zagreb, Ante Kovačića 1, 10000, Zagreb, Croatia.
| | - Srećko Marušić
- Department of Clinical Pharmacology, University Hospital Dubrava, Avenija Gojka Suska 6, 10000, Zagreb, Croatia
| | - Vesna Bačić-Vrca
- Department of Clinical Pharmacy, University Hospital Dubrava, Avenija Gojka Suska 6, 10000, Zagreb, Croatia
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8
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Delayed lumbar plexus palsy due to giant psoas hematoma associated with vertebral compression fracture and direct oral anticoagulants: a case report. BMC Musculoskelet Disord 2021; 22:377. [PMID: 33888106 PMCID: PMC8063304 DOI: 10.1186/s12891-021-04267-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background Osteoporotic vertebral compression fractures (VCFs) are commonly observed in elderly people and can be treated by conservatively with minimal risk of complications in most cases. However, utilization of direct oral anticoagulants (DOACs) increases the risks of secondary hematoma even after insignificant trauma. The use of DOACs increased over the past decade because of their approval and recommendation for both stroke prevention in non-valvular atrial fibrillation and treatment of venous thromboembolism. It is well known that DOACs are safer anticoagulants than warfarin in terms of major and nonmajor bleeding; however, we noted an increase in the number of bleeding events associated with DOACs that required medical intervention. This report describes the first case of delayed lumbar plexus palsy due to DOAC-associated psoas hematoma after VCF to draw attention to potential risk of severe complication associated with this type of common and stable trauma. Case presentation An 83-year-old man presented with his left inguinal pain and inability to ambulate after falling from standing position and was prescribed DOACs for chronic atrial fibrillation. Computed tomography angiography revealed a giant psoas hematoma arising from the ruptured segmental artery running around fractured L4 vertebra. Because of motor weakness of his lower limbs and expansion of psoas hematoma revealed by contrast computed tomography on day 8 of his hospital stay, angiography aimed for transcatheter arterial embolization was tried, but could not demonstrate any major active extravasation; therefore spontaneous hemostasis was expected with heparin replacement. On day 23 of his stay, hematoma turned to decrease, but dysarthria and motor weakness due to left side cerebral infarction occurred. His pain improved and bone healing was achieved about 2 months later from his admission, however the paralysis of the left lower limb and aftereffects of cerebral infarction remained after 1 year. Conclusion In patients using DOACs with multiple risk factors, close attention must be taken in vertebral injury even if the fracture itself is a stable-type such as VCF, because segmental artery injury may cause massive psoas hematoma followed by lumbar plexus palsy and other complications.
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9
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Puzio TJ, Murphy PB, Kregel HR, Ellis RC, Holder T, Wandling MW, Wade CE, Kao LS, McNutt MK, Harvin JA. Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis. J Am Coll Surg 2021; 232:1007-1016.e5. [PMID: 33766725 DOI: 10.1016/j.jamcollsurg.2021.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 12/26/2022]
Affiliation(s)
| | | | | | - Ryan C Ellis
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Travis Holder
- Houston Academy of Medicine-Texas Medical Center Library, Houston, TX
| | | | - Charles E Wade
- University of Texas Medical Center at Houston, Houston, TX
| | - Lillian S Kao
- University of Texas Medical Center at Houston, Houston, TX
| | | | - John A Harvin
- University of Texas Medical Center at Houston, Houston, TX
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10
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Groene P, Wagner D, Kammerer T, Kellert L, Giebl A, Massberg S, Schäfer ST. Viscoelastometry for detecting oral anticoagulants. Thromb J 2021; 19:18. [PMID: 33726769 PMCID: PMC7962229 DOI: 10.1186/s12959-021-00267-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/01/2021] [Indexed: 12/26/2022] Open
Abstract
Background Determination of anticoagulant therapy is of pronounced interest in emergency situations. However, routine tests do not provide sufficient insight. This study was performed to investigate the impact of anticoagulants on the results of viscoelastometric assays using the ClotPro device. Methods This prospective, observational study was conducted in patients receiving dabigatran, factor Xa (FXa)-inhibitors, phenprocoumon, low molecular weight heparin (LMWH) or unfractionated heparin (UFH) (local ethics committee approval number: 17–525-4). Healthy volunteers served as controls. Viscoelastometric assays were performed, including the extrinsic test (EX-test), intrinsic test (IN-test) Russel’s viper venom test (RVV-test), ecarin test (ECA-test), and the tissue plasminogen activator test (TPA-test). Results 70 patients and 10 healthy volunteers were recruited. Clotting time in the EX-test (CTEX-test) was significantly prolonged versus controls by dabigatran, FXa inhibitors and phenprocoumon. CTIN-test was prolonged by dabigatran, FXa inhibitors and UFH. Dabigatran, FXa inhibitors and UFH significantly prolonged CTRVV-test in comparison with controls (median 200, 207 and 289 vs 63 s, respectively; all p < 0.0005). Only dabigatran elicited a significant increase in CTECA-test compared to controls (median 307 vs 73 s; p < 0.0001). CTECA-test correlated strongly with dabigatran plasma concentration (measured by anti-IIa activity; r = 0.9970; p < 0.0001) and provided 100% sensitivity and 100% specificity for detecting dabigatran. Plasma concentrations (anti-XA activity) of FXa inhibitors correlated with CTRVV-test (r = 0.7998; p < 0.0001), and CTRVV-test provided 83% sensitivity and 64% specificity for detecting FXa inhibitors. Conclusions In emergency situations, ClotPro viscoelastometric assessment of whole-blood samples may help towards determining the presence and type of anticoagulant class that a patient is taking. Trial registration German clinical trials database ID: DRKS00015302. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00267-w.
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Affiliation(s)
- Philipp Groene
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Daniela Wagner
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Andreas Giebl
- Department of Transfusion Medicine and Hemostaseology, University Hospital Augsburg, Augsburg, Germany
| | - Steffen Massberg
- Department of Internal Medicine I - Cardiology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Simon Thomas Schäfer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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11
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Current use of rivaroxaban in elderly patients with venous thromboembolism (VTE). J Thromb Thrombolysis 2021; 52:863-871. [PMID: 33674983 DOI: 10.1007/s11239-021-02415-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 12/12/2022]
Abstract
Venous thromboembolism (VTE), which is characterized by pulmonary embolism and deep vein thrombosis, has become a serious public concern. Notably, over half of the patients with VTE are over 70 years of age, but elderly patients are at high risk of anti-coagulation and bleeding, which increase with age. Moreover, risk factors and frailty also show a difference between elderly patients and ordinary patients diagnosed with VTE. Rivaroxaban is a direct inhibitor of activated factor Xa and has the advantage of predictable pharmacodynamics and pharmacokinetics, no coagulation monitoring, and few drug interactions. As a first-line therapy for VTE, this drug is more advantageous than traditional therapy and exhibits good efficacy and safety for ordinary patients. However, the effectiveness and safety of rivaroxaban in elderly patients have not been fully elucidated. This article reviewed the use of rivaroxaban in elderly patients, including drug interactions, monitoring, reversal agents of rivaroxaban, and the use of small dosages of rivaroxaban in elderly patients.
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12
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Real-World Data on Characteristics and Management of Community Patients Receiving Anticoagulation Therapy Who Presented with Acute Bleeding to the Emergency Department at a Regional Australian Hospital: A Prospective Observational Study. Mediterr J Hematol Infect Dis 2021; 13:e2021017. [PMID: 33747398 PMCID: PMC7938926 DOI: 10.4084/mjhid.2021.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/05/2021] [Indexed: 11/08/2022] Open
Abstract
Objective To study patients receiving anticoagulants with or without antiplatelet therapy presenting at a regional Australian hospital with bleeding. The main aims are to explore: (1) patients' characteristics and management provided; (2) association between the type of anticoagulant and antiplatelet agent used and the requirement of reversal; (3) and the length of hospital stay (LoS) in conjunction with bleeding episode and management. Methods A prospective cross-sectional review of medical records of all patients who presented at a tertiary referral centre with bleeding while receiving anticoagulation therapy between January 2016 and June 2018. Data included: patients, demographics, investigations (kidney and liver function tests, coagulation profile, FBC), LoS, bleeding site, type of and reason for anticoagulation therapy, and management provided. Data analysis included descriptive statistics, χ2 association, and regression models. Results Among the 144 eligible patients, 75 (52.1%) were male, and the mean age was 76 years (SD=11.1). Gastrointestinal tract bleeding was the most common (n=48, 33.3%), followed by epistaxis (n=32, 22.2%). Atrial fibrillation was the commonest reason for anticoagulation therapy (n=65, 45.1%). Warfarin was commonly used (n=74, 51.4%), followed by aspirin (n=29, 20.1%), rivaroxaban (n=26, 18.1%), and apixaban (n=12, 8.3%). The majority had increased blood urea nitrogen (n=67, 46.5%), while 58 (40.3%) had an elevated serum creatinine level, and 59 (41.0%) had a mild reduction in eGFR. Thirty-five of the warfarinised patients (47.3%) had an INR above their condition's target range despite normal liver function. Severe anaemia (Hb<80g/L) was reported in 88 patients (61.1%). DOACs were associated with a reduced likelihood of receiving reversal (B= -1.7, P=<.001), and with a shorter LoS (B= -4.1, P=.046) when compared with warfarin, LMWH, and antiplatelet therapy. Conclusion Warfarin use was common among patients who presented with acute bleeding, and the INR in many warfarinised patients exceeded the target for their condition. DOACs were associated with a reduced likelihood of receiving reversal and a shorter LoS than warfarin, LMWH, which might support a broader application of DOACs into community practice.
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New options for anticoagulation in congenital and pediatric acquired heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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14
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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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15
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Rossi JM, Diamond SL. Scalable manufacture of a disposable, storage-stable eight-channel microfluidic device for rapid testing of platelet, coagulation, and drug function under whole blood flow. BIOMICROFLUIDICS 2020; 14:054103. [PMID: 33014235 PMCID: PMC7527242 DOI: 10.1063/5.0023312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/17/2020] [Indexed: 05/04/2023]
Abstract
Custom polydimethylsiloxane (PDMS) microfluidic devices allow for small-volume human blood research under hemodynamic conditions of bleeding and clotting. However, issues of PDMS molding/assembly, bio-coating, and sample preparation often limit their point-of-care use. We aim to develop a microfluidic device that has the same utility as previously established PDMS devices but which is more usable in point-of-care operation. We designed an injection-molded 1 × 3 in.2 device with eight flow paths crossing a bio-printed surface of a collagen/tissue factor. The device is rapidly primed and compatible with multi-channel pipetting (<0.5 ml blood) and operates under venous or arterial shear rates using constant flow rate or constant pressure modes. Platelet and fibrin deposition were monitored dynamically by the imaging of immunofluorescence. For whole blood clotting at a wall shear rate of 200 s-1, the intrachip CV at 400 s for platelet and fibrin deposition was 10% and the interdonor CV at 400 s was 30% for platelet and 22% for fibrin deposition (across 10 healthy donors). No significant difference was detected for samples tested on a new chip vs a chip stored for 6 months at 4 °C. Using the fibrin signal, dose-response testing of whole blood revealed IC50's of 120 nM for rivaroxaban and apixaban, and 60 nM for dabigatran. A complete reversal of apixaban inhibition was observed for an equimolar addition of Xa DOAC reversal agent Andexanet Alfa. We demonstrate the ability to manufacture single-use, storage-stable eight-channel chips. In clinical settings, such chips may help evaluate patient bleeding risk, therapy choice, drug activity, or reversal.
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Affiliation(s)
| | - Scott L. Diamond
- Author to whom correspondence should be addressed:. Tel.: +1 215 573 5704. Fax: +1 215 573 6815
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16
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Exner T, Rigano J, Favaloro EJ. The effect of DOACs on laboratory tests and their removal by activated carbon to limit interference in functional assays. Int J Lab Hematol 2020; 42 Suppl 1:41-48. [DOI: 10.1111/ijlh.13196] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Joseph Rigano
- Haematology Department Alfred Hospital Melbourne Vic. Australia
| | - Emmanuel J. Favaloro
- Laboratory Haematology Institute of Clinical Pathology and Medical Research (ICPMR) NSW Health Pathology Westmead Hospital Sydney NSW Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead Hospital Sydney NSW Australia
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17
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Kiyosawa N, Watanabe K, Morishima Y, Yamashita T, Yagi N, Arita T, Otsuka T, Suzuki S. Exploratory Analysis of Circulating miRNA Signatures in Atrial Fibrillation Patients Determining Potential Biomarkers to Support Decision-Making in Anticoagulation and Catheter Ablation. Int J Mol Sci 2020; 21:ijms21072444. [PMID: 32244749 PMCID: PMC7178177 DOI: 10.3390/ijms21072444] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/24/2022] Open
Abstract
Novel biomarkers are desired to improve risk management for patients with atrial fibrillation (AF). We measured 179 plasma miRNAs in 83 AF patients using multiplex qRT-PCR. Plasma levels of eight (i.e., hsa-miR-22-3p, hsa-miR-128-3p, hsa-miR-130a-3p, hsa-miR-140-5p, hsa-miR-143-3p, hsa-miR-148b-3p, hsa-miR-497-5p, hsa-miR-652-3p) and three (i.e., hsa-miR-144-5p, hsa-miR-192-5p, hsa-miR-194-5p) miRNAs showed positive and negative correlations with CHA2DS2-VASc scores, respectively, which also showed negative and positive correlations with catheter ablation (CA) procedure, respectively, within the follow-up observation period up to 6-month after enrollment. These 11 miRNAs were functionally associated with TGF-β signaling and androgen signaling based on pathway enrichment analysis. Seven of possible target genes of these miRNAs, namely TGFBR1, PDGFRA, ZEB1, IGFR1, BCL2, MAPK1 and DICER1 were found to be modulated by more than four miRNAs of the eleven. Of them, TGFBR1, PDGFRA, ZEB1 and BCL2 are reported to exert pro-fibrotic functions, suggesting that dysregulations of these eleven miRNAs may reflect pro-fibrotic condition in the high-risk patients. Although highly speculative, these miRNAs may potentially serve as potential biomarkers, providing mechanistic and quantitative information for pathophysiology in daily clinical practice with AF such as possible pro-fibrotic state in left atrium, which would enhance the risk of stroke and reduce the preference for performing CA.
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Affiliation(s)
- Naoki Kiyosawa
- Specialty Medicine Research Laboratories I, Daiichi Sankyo Co., Ltd., Tokyo 140-0005, Japan
- Correspondence: ; Tel.: +81-3-5740-3412
| | - Kenji Watanabe
- Biomarker & Translational Research Department, Daiichi Sankyo Co., Ltd., Tokyo 140-0005, Japan;
| | - Yoshiyuki Morishima
- Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo 103-8426, Japan;
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo 106-0031, Japan; (T.Y.); (T.A.); (T.O.); (S.S.)
| | - Naoharu Yagi
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo 106-0031, Japan; (T.Y.); (T.A.); (T.O.); (S.S.)
| | - Takuto Arita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo 106-0031, Japan; (T.Y.); (T.A.); (T.O.); (S.S.)
| | - Takayuki Otsuka
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo 106-0031, Japan; (T.Y.); (T.A.); (T.O.); (S.S.)
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo 106-0031, Japan; (T.Y.); (T.A.); (T.O.); (S.S.)
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Santana-Romo F, Lagos CF, Duarte Y, Castillo F, Moglie Y, Maestro MA, Charbe N, Zacconi FC. Innovative Three-Step Microwave-Promoted Synthesis of N-Propargyltetrahydroquinoline and 1,2,3-Triazole Derivatives as a Potential Factor Xa (FXa) Inhibitors: Drug Design, Synthesis, and Biological Evaluation. Molecules 2020; 25:molecules25030491. [PMID: 31979319 PMCID: PMC7037264 DOI: 10.3390/molecules25030491] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/19/2020] [Accepted: 01/20/2020] [Indexed: 12/22/2022] Open
Abstract
The coagulation cascade is the process of the conversion of soluble fibrinogen to insoluble fibrin that terminates in production of a clot. Factor Xa (FXa) is a serine protease involved in the blood coagulation cascade. Moreover, FXa plays a vital role in the enzymatic sequence which ends with the thrombus production. Thrombosis is a common causal pathology for three widespread cardiovascular syndromes: acute coronary syndrome (ACS), venous thromboembolism (VTE), and strokes. In this research a series of N-propargyltetrahydroquinoline and 1,2,3-triazole derivatives as a potential factor Xa (FXa) inhibitor were designed, synthesized, and evaluated for their FXa inhibitor activity, cytotoxicity activity and coagulation parameters. Rational design for the desired novel molecules was performed through protein-ligand complexes selection and ligand clustering. The microwave-assisted synthetic strategy of selected compounds was carried out by using Ullmann-Goldberg, N-propargylation, Mannich addition, Friedel-Crafts, and 1,3-dipolar cycloaddition type reactions under microwave irradiation. The microwave methodology proved to be an efficient way to obtain all novel compounds in high yields (73–93%). Furthermore, a thermochemical analysis, optimization and reactivity indexes such as electronic chemical potential (µ), chemical hardness (η), and electrophilicity (ω) were performed to understand the relationship between the structure and the energetic behavior of all the series. Then, in vitro analysis showed that compounds 27, 29–31, and 34 exhibited inhibitory activity against FXa and the corresponding half maximal inhibitory concentration (IC50) values were calculated. Next, a cell viability assay in HEK293 and HepG2 cell lines, and coagulation parameters (anti FXa, Prothrombin time (PT), activated Partial Thromboplastin Time (aPTT)) of the most active novel molecules were performed to determine the corresponding cytotoxicity and possible action on clotting pathways. The obtained results suggest that compounds 27 and 29 inhibited FXa targeting through coagulation factors in the intrinsic and extrinsic pathways. However, compound 34 may target coagulation FXa mainly by the extrinsic and common pathway. Interestingly, the most active compounds in relation to the inhibition activity against FXa and coagulation parameters did not show toxicity at the performed coagulation assay concentrations. Finally, docking studies confirmed the preferential binding mode of N-propargyltetrahydroquinoline and 1,2,3-triazole derivatives inside the active site of FXa.
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Affiliation(s)
- Fabián Santana-Romo
- Departamento de Química Orgánica, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Av. Vicuña Mackenna 4860, Macul, Santiago 7820436, Chile; (F.S.-R.); (F.C.); (N.C.)
| | - Carlos F. Lagos
- Chemical Biology & Drug Discovery Laboratory, Facultad de Medicina y Ciencia, Universidad San Sebastián, Lota 2465, Providencia 7510157, Santiago de Chile, Chile;
| | - Yorley Duarte
- Center for Bioinformatics and Integrative Biology, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago 8370146, Chile;
| | - Francisco Castillo
- Departamento de Química Orgánica, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Av. Vicuña Mackenna 4860, Macul, Santiago 7820436, Chile; (F.S.-R.); (F.C.); (N.C.)
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Av. Vicuña Mackenna 4860, Macul, Santiago 7820436, Chile
| | - Yanina Moglie
- Departamento de Química, Instituto de Química del Sur (INQUISUR-CONICET), Universidad Nacional del Sur Avenida Alem 1253, Bahía Blanca B8000CPB, Argentina;
| | - Miguel A. Maestro
- Department of Chemistry—CICA, University of A Coruña, Campus da Zapateira, 15008A A Coruña, Spain;
| | - Nitin Charbe
- Departamento de Química Orgánica, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Av. Vicuña Mackenna 4860, Macul, Santiago 7820436, Chile; (F.S.-R.); (F.C.); (N.C.)
| | - Flavia C. Zacconi
- Departamento de Química Orgánica, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Av. Vicuña Mackenna 4860, Macul, Santiago 7820436, Chile; (F.S.-R.); (F.C.); (N.C.)
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Av. Vicuña Mackenna 4860, Macul, Santiago 7820436, Chile
- Correspondence: ; Tel.: +56-2354-1150
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