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Anticoagulation with the DOACs

Tom Deloughery, MD and Matthieu DeClerck, MD
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It’s time for Hematology Rounds with Dr. Tom DeLoughery! In this segment, he and our own Matt DeClerck review the indications for and potential benefits and pitfalls of the direct oral anticoagulants (DOACs).

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Ian L., Dr -

There will be a need to measure the levels of the effects of the DOACs- the dilute thrombin time and the Chromogenic Antifactor X levels .
They can be measured and with a turn around time of thirty minutes according to Professor A Tropodi and Angelo Bianchi Bonomi Hemophilia and Thrombosis Milano in the Pol Arch Intern MED 2018 128 (6)!379-385 .
With Dr Jeffrey I Weitz and Dr John W Eikelboom in Urgent Need to Measure the Effects of Direct Oral AntiCoagulants in Circulation 2016 ;134:186-188 these authors detail when clinical circumstances need levels.
When making decisions about the timing of urgent surgery or interventions
Determining whether patients with ischaemic stroke can be safely given fibrinolytic therapy
The context of overdose of DOACS
Adding a new medication not tested for interaction with DOACS .
Acute illness particularly leading to variations in Creatinine clearance - even dehydration in hot climates or gastroenteritis .
Bleeding episodes and determining the contribution of DOACS .
Drs Weitz and Eikelboom have a table of the Tests : Diluted Thrombin time for Dabigatran and Calibrated anti factor Xa and the Laboratory Assay Labs accredited in Europe to measure the assays .
They urge regulatory agencies and hospitals to get on board and make this happen.
What are the views of Drs T Deloughery and M De Clerk ?

Neda F., MD -

Thanks for your comment and question, Ian. I've asked Dr. Deloughery for his thoughts and will keep you posted when I hear back.

Neda F., MD -

Hi Ian. Dr. Deloughery wrote back with the following response. I find it very helpful, actually!

"So the bottom line this is a vexing issue! I view the thrombin time and anti-Xa as more “Yes/No” there are DOACs on board. So far I prefer to get specific levels via references labs.
How I used these
· Compliance – guy on apixaban has a new Dvt – breakthrough or failure to take med? I will ask the ED to get a anti-Xa
· Bleeding – do they have a DOAC on board? For example was consulted for acute GI bleeding in a patient on apixaban – had a high anti-Xa so gave PCC
· Renal disease – will send specific levels to ensure in range
· Obesity – will send specific levels to ensure in range
I tend to send specific levels to referral labs because I am not in a big hurry to get them and need it to make dosing decisions. As noted so far the test kits used for anti-Xa and thrombin time need to be calibrated by each lab to measure levels which most labs its not effective.
The other issues is what to do with the levels? I have sent scores and literally have only change dosing once. The published therapeutic ranges are broad and the correlation with clinical outcomes are uncertain."

Ian L., Dr -

Thank you for that feedback .
With patients on these medications for years and likely to have inter current illness or procedures we will need levels .
Very Fortunately they have the great advantage in reducing intracranial bleeding by half or more and antidotes are emerging that are good .

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