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New in Coagulation


Monday, December 5, 2016

What's New in Coagulation - December 2016

Written By Donna Castellone, MS, MT (ASCP) SH | LinkedIn

Want to be in the know? Check out our monthly compilation of the latest studies, guidelines, and discussions in coagulation.

Please note - many linked teasers require registered account/subscription in order to view the full articles. Medscape registration is free of charge.


Comorbidities Common With pulmonary Embolism After Surgery

New research indicated that orthopedic patients who experience postoperative pulmonary embolism often have other diagnoses that contribute to their cardiorespiratory symptoms. This suggests that a PE rarely exists in isolation in this cohort and clinicians should consider testing this population. When reviewing chest CT angiograms, alternative explanations were expected for symptoms, however they found that most often there was also a PE, suggesting that it may not be wise to skip a scan when an alternative diagnosis is plausible. So all possible causes should be investigated. There was no significant difference in survival between those with pulmonary embolism and those without (100.0% vs 98.3%).


Report of Recurrent Immune Thrombocytopenia After Flu Shot


Case report describes 4.5-year-old with three admissions for ITP, each within a week of vaccine.

A case report from Israel published online Nov. 8 in Pediatrics, authors present the case of recurrent immune thrombocytopenia (ITP) which occurred one week after influenza vaccination. The patient (4.5 years old) presented with a decreased platelet count and mucosal bleeding. Platelet counts returned to normal within 10 days post IV immunoglobulin. Most noted was the previous incidents which occurred in this patient post influenza vaccine in 2010 and 2012. The child did not receive the vaccine in 2011 and had no symptoms of ITP.


Genetic Testing May Help ID VTE Risk in Breast Cancer Patients

Clinical Cancer research published an on line study in which genetic testing could help identify breast cancer patients at high risk for venous thromboembolism (VTE). The study was conducted in Sweden (n=4261). If a genetic risk was found, there was a 9.5% risk of VTE in those patients on chemotherapy versus 1.3 % risk in low genetic risk women. Adding age as a factor (>60) along with genetic risk the incidence was 25%.


Endobronchial Ultrasound Can ID Pulmonary Thromboembolism

A study in the Journal of Clinical Ultrasound found that endobronchial ultrasound (EBUS) can identify pulmonary thromboembolism. This study out of Turkey reviewed 548 EBUS procedures performed, they found that 0.7% (4/548) using this technique PE was discovered. These were confirmed by contrast enhanced computed tomography of the thorax in which three out of the four patients also had lung cancer.


AHA: Many A-Fib Patients Not Receiving Oral Anticoagulants

The American Heart Association reported at its annual meeting that half of patients hospitalized with atrial fibrillation aren't receiving oral anticoagulants (OACs). After analysis of 1570456 AF admissions at 812 hospitals in the US over 5 years, it was noted that only 46% of patients were given OAC’s after discharge. This may be due to poor understanding about the condition and the risk of stroke which was noted to be 2 or higher in this cohort of patients aged 40 years and older. Other contributing factors may be concerns about use of the drugs in these patients and that they should be provided as an outpatient versus an inpatient setting.


EUCLID: Ticagrelor, Clopidogrel in PAD Similar for CV Events, Bleeding

The Euclid trial was a double blinded study conducted in 28 countries involving 13855 patients who were randomized to either ticagrelor or clopidrogrel who were diagnosed with peripheral artery disease (PAD). Their endpoint was cardiovascular death, MI, ischemic stroke and major bleeding. There was no significant difference using ticagrelor versus clopidogrel as primary efficacy occurred in 10.8% versus 10.6% of patients respectively. A statistically significant difference (p=0.03) was noted in the rate of ischemic stroke being 1.9% for ticagrelor versus 2.4% for clopidogrel. Adverse events of dsypnea and bleeding were higher in the ticagrelor group.


Data From Clinical Registries Can ID Novel Drug Interactions

Data mining can be a useful tool in identifying drug interactions. For this study, patients with AF who had been treated with warfarin and had a stable INR were investigated for altered PT after the initiation of novel prescriptions. A learning method was used to predict altered INR levels. Two hundred and twenty groups were analyzed in 61,190 novel prescriptions. Known drugs that causes interactions were found as well as three (platelet aggregation inhibitors, direct thrombin inhibitors and heparins) cause a decrease in INR, while an increasing INR was seen in antipropulsives.


Data Dabigatran Bleed Rish With Lovastatin, Simvastatin in Study Raises Eyebrows

A study looked at the concurrent use of dabigatran and stains on older AF patients. The outcome suggests that people who take lovastatin or simvastatin have more than a 40% increased relative risk of hemorrhage in comparison to other statins. The risk of this is low, but having knowledge of this is important.

These statins, as opposed to other statins, are potent inhibitors of intestinal P-glycoprotein which increases systemic dabigatran exposure. A solution may be to space the medication to attenuate any interaction.

It was questioned as to why this interaction was noted 7 years after the REL-Y trial. This may be due to the small numbers of patients on these drugs in this study. A flaw to the study is that no one has actually measured dabigatran levels while on statins. Other limitations include data on markers of kidney function, use of other non prescription drugs that can influence bleeding and the fact that these two drugs are older statins. People who were taking them, were on them for a longer time, and may represent a sicker population.


Dabigatran-Reversal Agent Fast, Effective in REVERSE AD, but Now What?

Idarucizumab is the reversal agent for dabigatran. This has demonstrated the ability to achieve cessation of bleeding in patients or those who needed urgent surgery. The effect occurs within 4 hours and lasts 2 days. Many patients are able to return to dabigatran within days. Two bolus doses are given and reversal is seen within 10 minutes.

The RE-VERSE AD trial included 2 groups: those with uncontrolled bleeding (n=298) and those who required urgent procedures or surgery (n=196). Serious bleeds in group A were gastrointestinal in 135 cases and intracranial in 97, with a variety of sites making up the rest. The emergent-surgery indication included acute abdomen in 45 patients, bone fracture in 30, infections in 20, and pacemaker implantation in 10.

In question is how and when to use this reversal agent in clinical practice, when is it needed for effective management? The drug is expensive but would make sense in a patient with major trauma or an ICH. Other instances may not require use so it will need to be evaluated on a case by case basis. However, knowing that there is a reversal agent may reassure clinicians to be able to give agents in patients they originally thought were too frail. Reversal was measured using a dilute thrombin time which returned to normal within 4 hours, the same result was seen when testing with an ecarin clotting time. Making the average return to hemostasis between 3.5-4.5 hours.

Dabigatran was restarted in 2/3 of cases. The 30 day rate of thrombotic events was about 4,5%, and included strokes, DVT, MI, PE and both DVT and PE.


INTERESTING ABSTRACTS:

Successful Thrombolysis With Recombinant Tissue Plasminogen Activator After Antagonizing Dabigatran by Idarucizumab

Annemarie Gawehn; Yassine Ayari; Christian Heuschkel; Matthias Kaste; Pawel Kermer
J Med Case Reports. 2016;10(269).

Abstract

Background: Effective anticoagulation routinely precludes patients from receiving intravenous thrombolysis with recombinant tissue plasminogen activator to reverse severe symptoms of ischemic stroke. We report what we believe to be the first case of ischemic stroke successfully treated with recombinant tissue plasminogen activator after antagonizing dabigatran with the monoclonal antibody idarucizumab, recently approved worldwide.

Case presentation: A 75-year-old Caucasian man presented to our hospital with severe aphasia and mild hemiparesis. After providing written consent, he received two doses of 2.5 g of idarucizumab over 20 minutes followed by standard protocol in-label recombinant tissue plasminogen activator application. All symptoms resolved within 1 h.

Conclusions: A Applying a recombinant tissue plasminogen activator after antagonizing dabigatran with idarucizumab is feasible and easy to manage in an emergency room or stroke unit. Thus, idarucizumab represents a new therapeutic option for patients receiving dabigatran treatment, reestablishing their eligibility for recombinant tissue plasminogen activator thrombolysis.


Topical Versus Intravenous Tranexamic Acid Use in Total Knee Arthroplasty

Zach Arntson, DO; Adam Ferguson, DO; David C. Markel, MD
Curr Orthop Pract. 2016;27(5):520-523.

Abstract and Introduction

Abstract

Background: Topical or intravenous application of tranexamic acid (TXA) during total knee arthroplasty has been shown to reduce postoperative bleeding and transfusion rates. The objective of this study was to compare the efficacy and safety of topical and intravenous TXA at a single institution.

Methods: Four hundred and eighty-two patients were reviewed retrospectively, with 166 patients included as a non-TXA control group, and 70 in the topical TXA group and 48 in the intravenous TXA group. The primary outcomes were transfusion rates and blood loss calculated from the difference between preoperative and postoperative hemoglobin levels. Thromboembolic complications were recorded up to 90 days postoperatively.

Results: After TXA use, the mean hemoglobin levels were significantly higher in the topical (10.5 g/dL) and intravenous TXA groups (10.4 g/dL) when compared to the control group (9.6 g/dL) (P<0.001). This resulted in ~18% less blood loss postoperatively when comparing both the intravenous and topical cohorts. The transfusion rate for the control group (12.7%; 21/166) was higher than rates for the intravenous (2.1%; 1/48) and topical (4.3%; 3/70) TXA cohorts (P=0.023). There were no differences in complication rates among cohorts.

Conclusions: During cemented total knee arthroplasty, both topical and intravenous application of TXA resulted in significant reductions in postoperative bleeding and transfusion rates. There were no statistically significant changes in complication rates in either treatment group compared with the control group. Both topical and intravenous TXA appeared safe and effective in reducing postoperative bleeding and transfusion rates in cemented total knee arthroplasty.





 




 
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