Direct oral anticoagulants: When to consider laboratory testing?

Cate, Hugo Ten; Olie, Renske H.; Cate‐Hoek, Arina J. ten; Henskens, Yvonne

doi:10.1111/ijlh.12816

Cited by 11 publications

(9 citation statements)

References 20 publications

(28 reference statements)

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“…As compliance is a known major issue with many medications and skipping only one dose plays no role in VKA compared to DOAC, further research is needed on the inclusion of DOAC level measurements in clinical routine practice. 17 In contrast to this, INR measurements are part of routine evaluation and confirmed therapeutic VKA levels in the majority of our patients. The combination of DOAC or VKA and inhibitors of platelet aggregation has been previously found to increase the risk of hematuria-related complications, including hospital admissions.…”

Section: Primary Outcomes: Hospitalization Rate and Losmentioning

confidence: 45%

Shorter Hospital Stay and Fewer Hospitalizations in Patients With Visible Hematuria on Direct Oral Anticoagulants Compared to on Vitamin K Antagonists

Mûller

Bosshard

Nagler

et al. 2019

Urology

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OBJECTIVETo investigate the influence of type of anticoagulation − direct oral anticoagulants (DOAC) vs vitamin K antagonists (VKA) − on length of hospital stay (LOS) and hospitalization rates in patients with visible hematuria, as visible hematuria in anticoagulated patients can be distressing, difficult to control and even life-threatening. METHODSThis retrospective cohort study was conducted at the emergency department (ED) of a tertiary university hospital in Switzerland. All patients admitted with visible hematuria from January 1, 2013 to December 31, 2016 were included. We compared the primary clinical outcome parameters (hospitalization rate and LOS) as well as secondary outcomes (ICU admission, ED LOS, and in-hospital mortality) in patients with visible hematuria on either DOAC therapy, VKA therapy or no anticoagulants. RESULTSWe included 811 (100%) patients with visible hematuria; 53 (6.5%) patients were on DOAC, compared to 85 (10.5%) on VKA and 673 (83.0%) patients without any anticoagulation. In confounder-adjusted multivariable testing, there were fewer hospitalizations (odds ratio: 2.2, 95% confidence interval [CI]:1.1-4.9, P = .028) and shorter LOS (geometric mean ratio: 2.2, 95% CI: 1.3-4.0, P = .006) on DOAC than on VKA. The secondary outcomes were not significantly associated with the anticoagulation groups. No differences were found between the DOAC and no-anticoagulant groups for any outcome. CONCLUSIONVisible hematuria in patients on DOAC therapy is associated with shorter hospital stays and fewer hospitalizations compared to VKA. UROLOGY 132: 101−108, 2019.

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Section: Primary Outcomes: Hospitalization Rate and Losmentioning

confidence: 45%

Shorter Hospital Stay and Fewer Hospitalizations in Patients With Visible Hematuria on Direct Oral Anticoagulants Compared to on Vitamin K Antagonists

Mûller

Bosshard

Nagler

et al. 2019

Urology

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“…Furthermore, in contrast to VKAs, which require routine INR testing, routine drug monitoring for DOACs is not required since pharmacokinetics are predictable [5]. However, emergency situations, including stroke or acute bleeding situations, require exact and fast tests to detect whether a patient has relevant DOAC plasma concentrations, especially if the patient is unconscious and drug history is not available [6][7][8][9]. Furthermore, it is important to differentiate the two classes of DOACs (direct factor Xa inhibitors (DXaIs) and direct thrombin inhibitors (DTIs)), as well as DOACs from VKAs and dilutional coagulopathy (DIL).…”

Section: Introductionmentioning

confidence: 99%

Point-of-care detection and differentiation of anticoagulant therapy - development of thromboelastometry-guided decision-making support algorithms

et al. 2021

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Background DOAC detection is challenging in emergency situations. Here, we demonstrated recently, that modified thromboelastometric tests can reliably detect and differentiate dabigatran and rivaroxaban. However, whether all DOACs can be detected and differentiated to other coagulopathies is unclear. Therefore, we now tested the hypothesis that a decision tree-based thromboelastometry algorithm enables detection and differentiation of all direct Xa-inhibitors (DXaIs), the direct thrombin inhibitor (DTI) dabigatran, as well as vitamin K antagonists (VKA) and dilutional coagulopathy (DIL) with high accuracy. Methods Following ethics committee approval (No 17–525-4), and registration by the German clinical trials database we conducted a prospective observational trial including 50 anticoagulated patients (n = 10 of either DOAC/VKA) and 20 healthy volunteers. Blood was drawn independent of last intake of coagulation inhibitor. Healthy volunteers served as controls and their blood was diluted to simulate a 50% dilution in vitro. Standard (extrinsic coagulation assay, fibrinogen assay, etc.) and modified thromboelastometric tests (ecarin assay and extrinsic coagulation assay with low tissue factor) were performed. Statistical analyzes included a decision tree analyzes, with depiction of accuracy, sensitivity and specificity, as well as receiver-operating-characteristics (ROC) curve analysis including optimal cut-off values (Youden-Index). Results First, standard thromboelastometric tests allow a good differentiation between DOACs and VKA, DIL and controls, however they fail to differentiate DXaIs, DTIs and VKAs reliably resulting in an overall accuracy of 78%. Second, adding modified thromboelastometric tests, 9/10 DTI and 28/30 DXaI patients were detected, resulting in an overall accuracy of 94%. Complex decision trees even increased overall accuracy to 98%. ROC curve analyses confirm the decision-tree-based results showing high sensitivity and specificity for detection and differentiation of DTI, DXaIs, VKA, DIL, and controls. Conclusions Decision tree-based machine-learning algorithms using standard and modified thromboelastometric tests allow reliable detection of DTI and DXaIs, and differentiation to VKA, DIL and controls. Trial registration Clinical trial number: German clinical trials database ID: DRKS00015704.

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“…First, most laboratory assays developed to monitor antithrombotic drugs assess one specific hemostasis pathway. Clear examples are the direct thrombin inhibitors (dabigatran) and factor (F)Xa-inhibitors (rivaroxaban, apixaban, edoxaban), which concentrations are monitored by using the diluted thrombin time and the anti-Xa assay, respectively ( 8 ). Alternatively, residual platelet reactivity in patients on antiplatelet drugs (e.g.…”

Section: Introductionmentioning

confidence: 99%

Rotational Thromboelastometry in High-Risk Patients on Dual Antithrombotic Therapy After Percutaneous Coronary Intervention

Hulshof

Olie

Vries

et al. 2021

Front. Cardiovasc. Med.

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Aims: Patients using antithrombotic drugs after percutaneous coronary intervention (PCI) are at risk for bleeding and recurrent ischemia. We aimed to explore routine and tissue plasminogen activated (tPA) ROTEM results in a post-PCI population on dual antithrombotic treatment.Methods and Results: In this prospective cohort, 440 patients treated with double antithrombotic therapy after recent PCI and with ≥3 risk factors for either ischemic or bleeding complications were included and compared with a control group (n = 95) consisting of perioperative patients not using antithrombotic medication. Laboratory assessment, including (tPA) ROTEM, was performed one month post-PCI and bleeding/ischemic complications were collected over a five-month follow-up. Patients were stratified by antithrombotic regimen consisting of a P2Y12 inhibitor with either aspirin (dual antiplatelet therapy; DAPT, n = 323), a vitamin K antagonist (VKA, n = 69) or a direct oral anticoagulant (DOAC, n = 48). All post-PCI patients had elevated ROTEM clot stiffness values, but only the DAPT group additionally presented with a decreased fibrinolytic potential as measured with tPA ROTEM. Patients receiving anticoagulants had prolonged clotting times (CT) when compared to the control and DAPT group; EXTEM and FIBTEM CT could best discriminate between patients (not) using anticoagulants (AUC > 0.97). Furthermore, EXTEM CT was significantly prolonged in DAPT patients with bleeding complications during follow-up (68 [62–70] vs. 62 [57–68], p = 0.030).Conclusion: ROTEM CT has high potential for identifying anticoagulants and tPA ROTEM could detect a diminished fibrinolytic potential in patients using DAPT. Furthermore, the ability of EXTEM CT to identify patients at risk for bleeding may be promising and warrants further research.

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Direct oral anticoagulants: When to consider laboratory testing?

Cited by 11 publications

References 20 publications

Shorter Hospital Stay and Fewer Hospitalizations in Patients With Visible Hematuria on Direct Oral Anticoagulants Compared to on Vitamin K Antagonists

Shorter Hospital Stay and Fewer Hospitalizations in Patients With Visible Hematuria on Direct Oral Anticoagulants Compared to on Vitamin K Antagonists

Point-of-care detection and differentiation of anticoagulant therapy - development of thromboelastometry-guided decision-making support algorithms

Rotational Thromboelastometry in High-Risk Patients on Dual Antithrombotic Therapy After Percutaneous Coronary Intervention

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