Newer oral anticoagulants: A review of laboratory monitoring options and reversal agents in the hemorrhagic patient

Miyares, Marta A.; Davis, Kyle

doi:10.2146/ajhp110725

Cited by 97 publications

(137 citation statements)

References 61 publications

(71 reference statements)

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“…The Randomized Evaluation of Long-term Anticoagulant Therapy (RE-LY trial) reported a 1.45% per year incidence of lifethreatening bleeding or death related to bleeding complications from treatment with dabigatran, and this led to safety advisories being issued in several countries. 6,13 Agents that may be used to reverse the effects of dabigatran such as the activated prothrombin complex concentrate (FEIBA; Baxter, Deerfield, Illinois) and the recently approved 4-component prothrombin complex concentrate (Kcentra; CSL Behring, King of Prussia, Pennsylvania) may be effective, but without laboratory guidance the dosing is difficult, and thrombosis may result.…”

Section: Commentmentioning

confidence: 99%

“…In some cases, there are no useful methods to detect and monitor these agents, and no ''antidotes'' are available to reverse their effects. Miyares and Davis 13 recently reviewed the usefulness and sensitivity of current coagulation assays for dabigatran, rivaroxaban, and apixaban. The most easily available tests for emergency situations, prothrombin time and partial thromboplastin time, were described as ''not ideal'' with the exception of the partial thromboplastin time for dabigatran.…”

mentioning

confidence: 99%

“…The most easily available tests for emergency situations, prothrombin time and partial thromboplastin time, were described as ''not ideal'' with the exception of the partial thromboplastin time for dabigatran. 13 Less widely available tests, including thrombin time, ecarin clotting time, Heptest (American Diagnostica, Stamford, Connecticut), prothrombinase-induced clotting time, and chromogenic factor IIa, either do not correlate well with drug levels or are cumbersome and lengthy to perform. The difficulty of managing trauma patients receiving dabigatran was highlighted by Cotton et al in an editorial in which the authors emphasized that ''.…”

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confidence: 99%

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Use of Thromboelastography (TEG) for Detection of New Oral Anticoagulants

Dias¹,

Norem²,

Doorneweerd³

et al. 2015

Archives of Pathology & Laboratory Medicine

123

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Context.-The clinical introduction of new oral anticoagulants (NOACs) has stimulated the development of tests to quantify the effects of these drugs and manage complications associated with their use. Until recently, the only treatment choices for the prevention of venous thromboembolism in orthopedic surgical patients, as well as for stroke and systemic embolism in patients with atrial fibrillation, were vitamin K antagonists, antiplatelet drugs, and unfractionated and low-molecular-weight heparins. With the approval of NOACs, treatment options and consequent diagnostic challenges have expanded.Objective.-To study the utility of thromboelastography (TEG) in monitoring and differentiating between 2 currently approved classes of NOACs, direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban and apixaban).Design.-Blood samples from healthy volunteers were spiked with each NOAC in both the presence and absence of ecarin, and the effects on TEG were evaluated.Results.-Both the kaolin test reaction time (R time) and the time to maximum rate of thrombus generation were prolonged versus control samples and demonstrated a dose response for apixaban (R time within the normal range) and dabigatran. The RapidTEG activated clotting time test allowed the creation of a dose-response curve for all 3 NOACs. In the presence of anti-Xa inhibitors, the ecarin test promoted significant shortening of kaolin R times to the hypercoagulable range, while in the presence of the direct thrombin inhibitor only small and dose-proportional R time shortening was observed.Conclusions.-The RapidTEG activated clotting time test and the kaolin test appear to be capable of detecting and monitoring NOACs. The ecarin test may be used to differentiate between Xa inhibitors and direct thrombin inhibitors. Therefore, TEG may be a valuable tool to investigate hemostasis and the effectiveness of reversal strategies for patients receiving NOACs.

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Section: Commentmentioning

confidence: 99%

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Use of Thromboelastography (TEG) for Detection of New Oral Anticoagulants

Dias¹,

Norem²,

Doorneweerd³

et al. 2015

Archives of Pathology & Laboratory Medicine

123

View full text Add to dashboard Cite

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“…Concentrated clotting factor products containing one or more clotting factors are available for use as alternatives to FFP for reversal of warfarin and other oral anticoagulants. There are four major types of products: [9][10][11][12][13][14][15][16] • rFVIIa (NovoSeven RT, Novo Nordisk…”

Section: S14mentioning

confidence: 99%

Pharmacologic interventions for reversing the effects of oral anticoagulants

Kalus

2013

American Journal of Health-System Pharmacy

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“…Especially in case of hemorrhagic complications or in patients with high bleeding risk, it may be necessary to quantify the anticoagulant effects of dabigatran (7,8). Dager et al (9) showed that for every 25 ng/mL of dabigatran, INR increased 0.03 to 0.07 depending up the reagent and aPTT increased 4.6 seconds in average.…”

Section: Discussionmentioning

confidence: 99%