Comparison of calibrated chromogenic anti-Xa assay and PT tests with LC-MS/MS for the therapeutic monitoring of patients treated with rivaroxaban

Jonathan Douxfils; Anne Tamigniau; Bernard Chatelain; Christian Chatelain; Pierre Wallemacq; Jean-Michel Dogné; François Mullier

doi:10.1160/TH13-04-0274

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2013; 110(04): 723-731
DOI: 10.1160/TH13-04-0274

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

Comparison of calibrated chromogenic anti-Xa assay and PT tests with LC-MS/MS for the therapeutic monitoring of patients treated with rivaroxaban

Authors

Jonathan Douxfils^*

¹Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Belgium
Anne Tamigniau^*

²Laboratory of Clinical Chemistry, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
Bernard Chatelain

³Hematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), CHU UCL Mont-Godinne-Dinant , Université Catholique de Louvain, Belgium
Christian Chatelain

⁴Hematology Department, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), CHU UCL Mont-Godinne-Dinant , Université Catholique de Louvain, Belgium
Pierre Wallemacq

²Laboratory of Clinical Chemistry, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
Jean-Michel Dogné

¹Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Belgium
François Mullier^#

¹Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Belgium

³Hematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), CHU UCL Mont-Godinne-Dinant , Université Catholique de Louvain, Belgium

Abstract

Summary

Possibilities to monitor rivaroxaban therapy could be useful in certain circumstances. Prothrombin time (PT) or chromogenic anti-Xa assays such as the Biophen Direct Factor Xa Inhibitor^® (DiXaI) have been proposed to estimate rivaroxaban concentrations but are mainly based on in vitro studies. The study aim was to compare PT and Biophen DiXaI^® measurements with liquid chromatography-tandem mass spectrometry (LC-MS/MS) measurements in plasma samples from patients treated with Xarelto^®. Fifty-two plasma samples were included. PT was performed using Innovin^® and Triniclot PT Excel S^®. Biophen DiXaI^® was performed according to instructions from the manufacturer. The rivaroxaban plasma concentration ranged between 0 and 485 ng/ml as measured by LC-MS/MS. The limits of quantification were 30 ng/ml and 5 ng/ml for Biophen DiXaI^® and LC-MS/MS, respectively. The linear correlation between Biophen DiXaI^® and LC-MS/ MS analyses was high for all rivaroxaban concentrations (r² = 0.95). For concentrations ≤100 ng/ml, r²-value was 0.83. The Bland-Altman analysis showed a mean difference of −16 ng/ml (SD: 25 ng/ml). The PT methods did not correlate well with plasma concentrations measured by LC-MS/MS (r² ≈ 0.60). In conclusion, the important interindividual variability and the poor correlation with LC-MS/MS preclude the use of PT to estimate rivaroxaban concentrations. Thanks to its small inter-individual variability and good agreement with LC-MS/ MS measurements, we recommend the use of Biophen DiXaI^® assays to estimate concentrations of rivaroxaban >30 ng/ml. Quantification of low rivaroxaban levels (<30 ng/ml) requires the LC-MS/MS method.

Keywords

Rivaroxaban - monitoring - prothrombin time - chromogenic anti-Xa assay - LC-MS/MS

Full Text

References

References
1 E.M.A. EU - Summary of Product Characteristic: Xarelto. 05/02/2013. Available at http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000944/WC500057108.pdf Accessed April 30, 2013.
2 F.D.A. Label and Approval History for Rivaroxaban. Available at http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/022406s004lbl.pdf Accessed March 7, 2013.
3 Cohen AT, Dobromirski M. The use of rivaroxaban for short- and long-term treatment of venous thromboembolism. Thromb Haemost 2012; 107: 1035-1043.
4 Turpie AG, Lassen MR, Eriksson BI. et al. Rivaroxaban for the prevention of venous thromboembolism after hip or knee arthroplasty. Pooled analysis of four studies. Thromb Haemost 2011; 105: 444-453.
5 E.M.A. Summary of opinion - 21th March 2013 - Xarelto. 2013 Available at http://www.ema.europa.eu/docs/en_GB/document_library/Summary_of_opinion/human/000944/WC500140679.pdf Accessed March 25, 2013.
6 You JJ, Singer DE, Howard PA. et al. Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) e531S-e575S.
7 Skanes AC, Healey JS, Cairns JA. et al. Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control. Can J Cardiol 2012; 28: 125-136.
8 Camm AJ, Lip GY, De Caterina R. et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. Europace 2012; 14: 1385-1413.
9 Turpie AG, Kreutz R, Llau J. et al. Management consensus guidance for the use of rivaroxaban--an oral, direct factor Xa inhibitor. Thromb Haemost 2012; 108: 876-886.
10 Kubitza D, Roth A, Becka M. et al. Effect of hepatic impairment on the pharmacokinetics and pharmacodynamics of a single dose of rivaroxaban - an oral, direct Factor Xa inhibitor. Br J Clin Pharmacol. 2013. Epub ahead of print.
11 Kubitza D, Becka M, Mueck W. et al. Effects of renal impairment on the pharmacokinetics, pharmacodynamics and safety of rivaroxaban, an oral, direct Factor Xa inhibitor. Br J Clin Pharmacol 2010; 70: 703-712.
12 Mueck W, Eriksson BI, Bauer KA. et al. Population pharmacokinetics and pharmacodynamics of rivaroxaban--an oral, direct factor Xa inhibitor--in patients undergoing major orthopaedic surgery. Clin Pharmacokinet 2008; 47: 203-216.
13 Ten Cate H. Monitoring new oral anticoagulants, managing thrombosis, or both?. Thromb Haemost 2012; 107: 803-805.
14 Baglin T, Hillarp A, Tripodi A. et al. Measuring Oral Direct Inhibitors (ODIs) of thrombin and factor Xa: A recommendation from the Subcommittee on Control of Anticoagulation of the Scientific and Standardisation Committee of the International Society on Thrombosis and Haemostasis. J Thromb Haemost. 2013. Epub ahead of print.
15 Camici GG, Steffel J, Akhmedov A. et al. Dimethyl sulfoxide inhibits tissue factor expression, thrombus formation, and vascular smooth muscle cell activation: a potential treatment strategy for drug-eluting stents. Circulation 2006; 114: 1512-1521.
16 Douxfils J, Mullier F, Robert S. et al. Impact of dabigatran on a large panel of routine or specific coagulation assays. Laboratory recommendations for monitoring of dabigatran etexilate. Thromb Haemost 2012; 107: 985-997.
17 Douxfils J, Mullier F, Loosen C. et al. Assessment of the impact of rivaroxaban on coagulation assays: laboratory recommendations for the monitoring of rivaroxaban and review of the literature. Thromb Res 2012; 130: 956-966.
18 Samama MM, Amiral J, Guinet C. et al. An optimised, rapid chromogenic assay, specific for measuring direct factor Xa inhibitors (rivaroxaban) in plasma. Thromb Haemost 2010; 104: 1078-1079.
19 Rohde G. Determination of rivaroxaban--a novel, oral, direct Factor Xa inhibitor--in human plasma by high-performance liquid chromatography-tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2008; 872: 43-50.
20 Samama MM, Contant G, Spiro TE. et al. Evaluation of the anti-factor Xa chromogenic assay for the measurement of rivaroxaban plasma concentrations using calibrators and controls. Thromb Haemost 2012; 107: 379-387.
21 E.M.A. EU - Summary of Product Characteristic: Pradaxa. 07/02/2013. Available at http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000829/WC500041059.pdf Accessed April 30, 2013.
22 F.D.A. Clinical Pharmacology Biopharmaceutics Review(s) 2010. Available at http://www.accessdata.fda.gov/drugsatfda_docs/nda/2011/022406Orig1s000ClinPharmR.pdf Accessed March 13, 2013.
23 Baglin T, Keeling D, Kitchen S. et al. Effects on routine coagulation screens and assessment of anticoagulant intensity in patients taking oral dabigatran or rivaroxaban: guidance from the British Committee for Standards in Haematology. Br J Haematol 2012; 159: 427-429.
24 Barrett YC, Wang Z, Frost C. et al. Clinical laboratory measurement of direct factor Xa inhibitors: anti-Xa assay is pReferable to prothrombin time assay. Thromb Haemost 2010; 104: 1263-1271.
25 Mani H, Rohde G, Stratmann G. et al. Accurate determination of rivaroxaban levels requires different calibrator sets but not addition of antithrombin. Thromb Haemost 2012; 108: 191-198.
26 Harenberg J, Kramer R, Giese C. et al. Determination of rivaroxaban by different factor Xa specific chromogenic substrate assays: reduction of interassay variability. J Thromb Thrombolysis 2011; 32: 267-271.
27 Samama MM, Contant G, Spiro TE. et al. Evaluation of the prothrombin time for measuring rivaroxaban plasma concentrations using calibrators and controls: results of a multicenter field trial. Clin Appl Thromb Hemost 2012; 18: 150-158.
28 Tripodi A, Chantarangkul V, Guinet C. et al. The International Normalized Ratio calibrated for rivaroxaban has the potential to normalize prothrombin time results for rivaroxaban-treated patients: results of an in vitro study. J Thromb Haemost 2011; 9: 226-228.
29 van Veen JJ, Smith J, Kitchen S. et al. Normal prothrombin time in the presence of therapeutic levels of rivaroxaban. Br J Haematol 2013; 160: 859-861.
30 Mani H, Hesse C, Stratmann G. et al. Ex vivo effects of low-dose rivaroxaban on specific coagulation assays and coagulation factor activities in patients under real life conditions. Thromb Haemost 2013; 109: 127-136.