The investigators aim to determine the DOAC levels at peak, trough, 24, and 48 hours
after temporary discontinuation of apixaban, dabigatran, edoxaban, or rivaroxaban before
elective interventional procedures in Chinese patients.
The investigators hypothesize that DOAC metabolism is ethnically and pharmacogenomically
specific. We also hypothesize that discontinuation of DOAC for 24 hours may achieve a
coagulation status suitable for most interventional procedures among Asians, as opposed
to 48 hours recommended by western guidelines.
The investigators shall recruit DOAC patients who require medical procedures that require
DOAC interruption for 48 hours, such as colonoscopy, pleural biopsy, cardiac
catheterization, digital subtraction angiograph, etc. Eligible subjects shall undergo
DOAC level testing at peak, trough, 24, and 48 hours after discontinuation of DOAC for
elective medical procedures. The investigators shall also record their baseline
demographics, clinical assessments, medical comorbidities, blood parameters, and
concurrent medications.
Detailed study procedures are as follows:
The investigators shall screen the eligibility of patients under the care of the
pharmacist- led DOAC clinic, general medical clinic, or wards in the Prince of Wales
Hospital.
The investigators shall obtain informed consent for DOAC-REAL study from eligible
patients.
Participants will have blood pressure, pulse, body weight, and body height
measurements. Demographic information including age, gender, smoking, and drinking
status will be recorded.
The investigators shall record participants' medical comorbidities including
hypertension, diabetes mellitus, dyslipidemia, congestive heart failure, history of
ischemic stroke, major haemorrhage, ischemic heart disease, or malignancy.
The investigators shall document the DOAC type, dosage, intake routine, commencement
date, and compliance of each subject.
Concurrent medications including aspirin, clopidogrel, cilostazol, simvastatin,
atorvastatin, rosuvastatin, amiodarone, dronedarone, phenytoin, valproate,
levetiracetam, indomethacin, ibuprofen, diclofenac, celecoxib, etoricoxib,
rifampicin, or any cytochrome P450/ P-glycoprotein modulators, will be recorded.
Recruited patients will undergo DOAC peak level tests (see definition of peak level)
in addition to complete blood count, routine clotting profile, renal, liver function
tests.
The investigators shall educate the participants about periprocedural DOAC
management based on the existing guidelines ranging from 48-96 hours depending on
creatinine clearance.
DOAC level paired with routine clotting profile will also be taken at trough (see
definition of trough level), 24 hours, 48 hours, +/- 96 hours (if applicable) after
interruption for elective medical procedures.
DOAC will be resumed as soon as hemostasis is achieved. Patients will receive close
monitoring of neurological status. Any suspected cerebrovascular accidents will be
assessed immediately by a stroke specialist.
The investigators shall discharge the subject if he or she remains neurologically
and hemodynamically stable for 24 hours. A follow-up appointment will be scheduled
to review procedural findings and evaluate any bleeding or ischemic events 30 days
after the procedure.
Definition of peak and trough levels:
Peak level is defined as the DOAC level 2-3 hours after intake of apixaban, dabigatran,
edoxaban, or rivaroxaban. The investigators shall instruct patients to take their DOAC at
8am and schedule blood tests at 10am to 11am on the date of recruitment (i.e. peak
level). Trough level is defined as the DOAC level immediately before the next intended
dose of any of the 4 above DOACs. For twice daily apixaban and dabigatran, trough level
is defined as 12 hours after the last dose. While for once daily edoxaban and
rivaroxaban, trough level is defined as 24 hours after the last dose.
Blood Specimen Collection and Processing:
Blood samples are required for 1) specific coagulation assays, 2) liquid
chromatography-mass spectrometry, and 3) pharmacogenomics studies. 1 bottle of citrated
blood sample, 1 bottle of heparin-lithium blood sample, and 3 bottles of EDTA blood
samples will be sent to our hematology, pharmacy, and genomics laboratories in Prince of
Wales Hospital for storage and processing.
Specific coagulation assays:
Apixaban, edoxaban, and rivaroxaban binds to Factor Xa (FXa) without the mediation of
antithrombin. Once bound, FXa can no longer contribute to the coagulation process,
thereby inducing anticoagulation effect. Two levels of lyophilized calibrators prepared
from human citrated plasma by means of a dedicated process at two different
concentrations of apixaban and rivaroxaban (HemosIL apixaban and rivaroxaban Calibrators,
respectively) are used by the ACL TOP® to obtain anti-Xa level. Edoxaban is measured with
the Technochrome anti-Xa kit (technoclone). Dabigatran level will be determined by
HemosIL Direct Thrombin Inhibitor (DTI) Assay, a modified dilute thrombin time test
performed on citrated patient plasma. Citrated patient plasma is diluted in pooled normal
plasma (DTI Plasma Diluent - supplied as part of the assay) to reduce interferences from
pre-analytical variables. A fixed concentration of reconstituted bovine thrombin is then
added to the diluted patient sample, activating the coagulation cascade and converting
fibrinogen into fibrin. The presence of Dabigatran in patient samples will have an
inhibitory effect on the procoagulant activity of the exogenous thrombin added to the
patient sample. The associated clotting time in seconds is measured on the ACL TOP®
Hemostasis Testing Systems.
Liquid chromatography-mass spectrometry:
This study involves the quantitative analysis of direct oral anticoagulants (DOAC) in
patients. The plasma concentrations of direct oral anticoagulants (apixaban, dabigatran,
edoxaban and rivaroxaban) will be determined by a validated assay using high-performance
liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). The method will
be developed and validated with respect to the assay precision, accuracy, specificity,
linearity, sensitivity, extraction recovery matrix effect and stability of analyte.
Briefly, DOAC in plasma samples will be extracted using protein precipitation,
liquid-liquid extraction or solid-phase extraction prior to LC-MS/MS analysis.
Calibration standards and quality control samples will be prepared by spiking known
amount of DOAC in drug-free plasma, and will be processed in the same manner as patient's
samples from the same run. A calibration curve of each DOAC will be constructed using the
chromatographic peak area ratio (analyte/internal standard) obtained from the calibration
standards, and the concentrations of DOAC in patient's sample will be quantified based on
the linear regression model obtained from the calibration curve.
Pharmacogenomics:
The genotypes of subjects will be determined by DNA microarray. Genomic DNA will be
isolated from peripheral blood samples by the DNeasy blood & tissue kit (QIAGEN,
Germany). The isolated DNA will be subject to library preparation and Infinium beadchip
(Illumina) analysis according to the manufacturer's instructions (Illumina, USA). The
beadchips will be scanned using an Illumina iScan System. To optimize the identification
of related genotypes (e.g., single-nucleotide polymorphisms), the Infinium Global
Diversity Array with Enhanced Pharmacogenomics (PGx) Content-8 v1.0 will be used.
Quantifying residual DOAC levels during the interruption periods may imply on duration of
periprocedural DOAC interruption, length of hospital-stay, and the risk of thromboembolic
and bleeding complications. Mapping inter- and intra-individual variations in DOAC levels
may also impact on the management of ischemic stroke among DOAC recipients. A prospective
study that reveals Asian-specific DOAC pharmacokinetic profiles may inform
cross-disciplinary, territory-wide periprocedural care and acute stroke intervention
strategy for the rapidly expanding DOAC population.