抗凝治疗的实验室监测长城会议课件

1、1抗凝治疗的实验室监测上海交通大学医学院附属瑞金医院王学锋1抗凝治疗的实验室监测上海交通大学医学院2A Cell-Based Model of Coagulation and Potential Targets 2A Cell-Based Model of Coagula3AT+ Xa + IIa(1:1 ratio)普通肝素1930sAT + Xa静脉间接Xa抑制剂2002IIa口服直接凝血酶抑制剂2004AT + Xa + IIa(Xa IIa)低分子量肝素1980sII, VII, IX, X(Protein C,S)华法林1940sXa口服直接Xa抑制剂2008抗凝药物发展史IIa静脉

2、直接凝血酶抑制剂1990s3AT+ Xa + IIa普通肝素1930sAT + Xa静OAT药物个体差异性遗传性因素:Hereditary resistance to warfarin 遗传性华法林抵抗(rare)Race种族获得性因素Variations in the metabolisms of vitamin K, OAT and coagulation factors 维生素K，口服抗凝药和凝血因子的代谢差异Pathologies (e.g. renal insufficiency)疾病（肾功能不全等）Age and weight 年龄和体重Drugs and diet 药物和饮食OA

3、T药物个体差异性遗传性因素: AVK 监测PT (1935):多种试剂缺乏统一标准室间差异大INR (1984):结果的标准化：统一使用ISI有所改善，然而 AVK 监测PT (1935):The goal of the monitoring is to maintain the patient within a narrow therapeutic range 监测目标：维持病人PT在一个狭窄的治疗范围内 PT监测OATApproximate therapeutic rangeRisk of thrombosisSafety / efficacy zoneRisk of bleedingPT

4、The goal of the monitoring is Therapeutic ranges有效浓度范围Therapeutic ranges have been recommended in INR by different representative groups 不同的机构推荐使用INR作为治疗范围的监测指标The most widely used come from the ACCP1, the BSCH2 or the GEHT3Therapeutic ranges given in range or in “target INR” American College of Che

5、st PhysiciansBritish Committee for Standards in HaematologyGroupement dEtude Hmostase et ThromboseTherapeutic ranges有效浓度范围TheraTherapeutic rangesOAT适应证及有效浓度范围适用于需长期持续抗凝的患者 Therapeutic rangesOAT适应证及有效浓度CAP survey 2007 CG-2CSame reagent / Different instruments00,20,40,60,811,2ABCDEFGHIJKLMINR00,511,52

6、2,533,5ABCDEFGHIJKLMINRINR 监测- OATCAP survey 2007 CG-2CSame reag10肝素治疗的实验室监测问题10肝素治疗的实验室监测问题11肝素与低分子量肝素肝素诱导的血小板减少症肝素抵抗常见问题11肝素与低分子量肝素肝素诱导的血小板减少症肝素抵抗常见问题12OOOOHOCOOOHOOOOHOOHHNSO3HNSO3OCOO -OSO3OSO3OSO3HNSO3OSO3OSO3OOH肝 素 Anticoagulant activity of AT is then enhanced by 1 000AT binds through the pent

7、asaccharideAT-Heparin complex inhibits serine proteases (Xa & IIa)12OOOOHOCOOOOOOHOOHHNSO3HNSO3O13MW 5400 Da ATPentaIIaATXaPenta 18 saccharide units ( MW 18 saccharide units ( MW 5400 Da) anti-Xa & anti-IIa activitiesAnti-IIa et anti-Xa activities : depend on molecular weight13MW 514UFH 监测所有患者主要副作用:

8、 抗凝效果延迟: 血栓进展或复发过度抗凝: 增加出血风险严重出血频率UFH : 5 %HIT (Heparin Induced Thrombocytopenia)WHY？14UFH 监测所有患者WHY？15LMWH 监测预防给药:不需要治疗给药:首次给药48小时后的剂量调整特殊情况: 体重过轻或过重 (160 Kg)肾功能损害 (creatinine clearance 30 mL/min)妊娠(3rd quarter)长期治疗新生儿 ( 2 months) or儿童 出血者效果不佳者15LMWH 监测预防给药:不需要16Which tests ?UFHLMWHPlatelet count P

9、latelet countAPTTAPTTAnti-Xa activity Anti-Xa activity AT : in case of heparin resistance; to detect any AT deficiency16Which tests ?UFHLMWHAT 17UFHChest. 2004;126:188S-203S.常用，迅速发挥作用无法预测剂量反应结合血浆蛋白 结合内皮细胞，巨噬细胞和血小板加强清除清除率差异 12倍高分子量排出快17UFHChest. 2004;126:188S-203S18UFH广泛使用，不正确使用出血风险大药物相关问题 出血 HIT需要多次

10、剂量调整，反复实验室监测开始每6h,稳定后每天一次输注对侧肢体采血Pharmacotherapy. 2004;24:146S-155S.Arch Pathol Lab Med. 1998;122:782-798.18UFH广泛使用，不正确使用出血风险大Pharmacoth19How to Monitor?aPTTHeparin Assay19How to Monitor?aPTTHeparin A20aPTT监测优点最常用便宜TAT时间短缺点治疗范围与试剂和批号有关普通凝血检测指标，肝素检测非特异只能用于 UFH, 不适合LMWH20aPTT监测优点21aPTT 试剂变异ReagentaPTT

11、 Range Corresponding to0.3 0.7 U/mLCorresponding Ratio(mean control)Actin54.6 87.61.9 3.4IL Test63.3 101.41.9 3.1Thrombosil I56.6 80.22.0 2.8Actin FSL84.4 124.02.6 3.8Actin FS85.6 134.12.7 4.3Arch Intern Med. 2001;161:385-391.21aPTT 试剂变异ReagentaPTT Range C22aPTT延长原因Blood Sampling(Pre-analytical)UFHC

12、ongenitalDeficienciesAcquiredDeficienciesAuto-AntibodiesLMWH: no relation to aPTT / drug dosageMainly hemophilia (VIII, IX)vWF / VIII (von Willebrands disease)II, V, XXI, XIIFibrinogen (hypo 0.8 g/L)DysfibrinogenemiaLiver diseaseDICVit K deficiencyWarfarin Specific (factors)Nonspecific (LA)Groce JB,

13、 Leumas J. Basic Skills in Interpreting Laboratory Data. 3rd ed. Am Soc Health System Pharmacists. May 2004.Potential to Under-CoagulateTube fillTube type22aPTT延长原因Blood SamplingUFHCon23 aPTT decreasedsensitivity to heparinheparin resistancehigh VIII/FibrinogenAT IIIdeficiencypregnancyrenal diseasep

14、ost thrombotic acute phase reactioninflammationPotential to Over-Anticoagulate23 aPTT decreasedhigh AT IIIpr24Br Med J. 1985;290:341-344. aPTT is the old “Gold Standard”24Br Med J. 1985;290:341-344. 25aPTT无法准确预测肝素水平不同试剂间一致性 47%不到治疗水平的 aPTT 68.5% 达到治疗的肝素水平Arch Intern Med. 1997;157:2475.25aPTT无法准确预测肝素

15、水平Arch Intern Me26aPTT vs. Heparin Assay持续aPTT不到治疗水平与VTE的发生或复发有关:Clin Appl Thromb Hemost. 1997:3:S64-67.24 h内治疗浓度达标:87% of patients using Anti-XaPharmacotherapy. 2004;24:713-719.57% of patients using aPTT (calibrated to Anti-Xa)Ann Intern Med. 1993;119:874-881.26aPTT vs. Heparin Assay持续aPTT27Weight-

16、based aPTT ProtocolCirculation. 2003;107:2884-2888.27Weight-based aPTT ProtocolCi28aPTT aPTT and Recurrent CV Events in UA / NSTEMIIncrease in Event Rates is Higher with Persistently Subtherapeutic Anticoagulation*CV events defined as CV death, MI, refractory anginaPercent recurrent CV events*RR=1.2

17、2(0.87-1.22)RR=1.84(1.25-2.70)P 0.005RR=2.21(1.47-3.31)P LMWH磺达肝睽钠(fondaparinux)外科术后内科患者妊娠妇女4lOd1114d14d女性男性病情重(如肿瘤或败血症)和高龄患者的风险高黑人白人 牛源猪源41临床特点危险因素 42临床特点血小板减少(诊断的先决条件)514 d,50109L80109L(100109L)，或较基础值下降50，且通常可在停用肝素l周后恢复正常最近曾接受过肝素治疗且体内存在抗肝素-PF4抗体，则再次接触肝素时血小板减少可在数分钟内出现无血小板减少并不能排除HIT诊断HIT相关的血栓事件可在血小板

18、减少之前出现42临床特点血小板减少(诊断的先决条件)434344诊 断4T诊断积分系统44诊 断4T诊断积分系统45实 验 诊 断45实 验 诊 断46实 验 诊 断46实 验 诊 断47实 验 诊 断血小板聚集实验的敏感性大于90，特异性范围为77100%47实 验 诊 断血小板聚集实验的敏感性大于90，特48实 验 诊 断48实 验 诊 断49抑制试验实 验 诊 断49抑制试验实 验 诊 断50实 验 诊 断50实 验 诊 断51实 验 诊 断51实 验 诊 断52实 验 诊 断52实 验 诊 断53诊 断53诊 断54肝素抵抗54肝素抵抗55MW 5400 Da ATPentaIIaAT

19、XaPenta 18 saccharide units ( MW 18 saccharide units ( MW 5400 Da) anti-Xa & anti-IIa activitiesAnti-IIa et anti-Xa activities : depend on molecular weight55MW 5 市场上的新抗凝药物rivaroxaban(XARELTO)apixaban (ELIQUIS)dabigatran (PRADAXA)XaIIaTF/VIIaXIXIXaVIIIaVaIIFibrinFibrinogenAdapted from Bates SM, Weitz

20、 JI. Br J Haematol 2006; 134: 3-19目前市场上的3种口服，单一剂量，无需监测的抗凝药物：两种直接Xa因子抑制剂一种直接IIa因子抑制剂 市场上的新抗凝药物rivaroxaban(XARELTO实验室监测或无需实验室监测实验室监测或无需实验室监测实验室监测或无需实验室监测无需监测但需要检测抗凝活性者特殊人群敏感人群，老年人，肾功能受损，肥胖患者威胁生命的情况出血，药物过量实验室监测或无需实验室监测无需监测可以使用哪些方法全球通用方法PTAPTT特殊方法依赖于抗凝靶点anti-Xa anti-IIa可以使用哪些方法全球通用方法特殊方法Effect of Rivaro

21、xaban, anti-Xa, on hemostasis teststesteffectPT, Sensitivity depending of the reagent; NO INRaPTTProlongation dependent of the reagent; not sensitiveFibrinogen Clauus: no effect; fromPT: UnderestimationTTNo effectCoagulant activity of factorsUnderestimation of factors level for high concentration of

22、 Rivaroxaban; depending of reagentsImmunological assays: D-D, FDP, factors, inhibitors, No effect on measurementAT activityReagents based on anti-Xa: overestimationReagents based on anti-IIa: no effect PC and PS anticoag. activityOverestimationAnti-Xa activitySpecific testActivated PC resistancecoag

23、ulation timeOver estimation of ratio: should not be usedF V Leiden, FII 20210A No effectAnticardiolipin ABAnd anti-2GP1 (ELISA)Coagulation tests: prolongedElisa: no effectEffect of Rivaroxaban, anti-XaEffect of Dabigatran, anti-IIa, on hemostasis teststesteffectPT, Sensitivity depending of the reage

24、nt; NO INRaPTTProlongation dependent of the reagent; not sensitiveFibrinogen Underestimation (Clauss +/-, from PT +)TT, Sensitivity+Coagulant activity of factorsUnderestimation for high concentration of Dabigatran; depending of reagentsImmunological assays: D-D, FDP, factors, inhibitors, No effect o

25、n measurementAT activityReagents based on anti-Xa (amidolytic): no effectReagents based on anti-IIa: overestimationPC and PS anticoag. activityOverestimation of levelsAnti-IIa activitySpecific testActivated PC resistancecoagulation timeOver estimation of ratio: should not be usedF V Leiden, FII 2021

26、0A No effectAnticardiolipin ABAnd anti-2GP1 (ELISA)Coagulation Tests prolongedElisa: no effectEffect of Dabigatran, anti-IIaAgent制备方法Anti-Xa / anti-IIa ratioMean molecular weightaPTT 延长Danaparoid sodium (Orgaran)动物肠粘膜：硫酸乙酰肝素（84），硫酸皮肤素（12） 206,500 D-Dalteparin (Fragmin)亚硝酸解聚2.55,000 D+/-Enoxaparin (L

27、ovenox, Clexane)苄基+碱性解聚3.64,500 D+/-Nadroparin (Fraxiparin)亚硝酸解聚2.5 - 44,300 D+/-Tinzaparin (Innohep)解聚酶（肝素）26,500 D+Fondaparinux (Arixtra)人工合成化合物1,750 D-新型胃肠外药物Agent制备方法Anti-Xa / anti-IIa ra STA-Liquid anti-XaAssay of anti-Xa activity using the amidolytic method： 抗-Xa酰胺分解法1 step competition reactio

28、n 一步竞争法“Heparin” colorimetric assay比色法UFHLMWHFondaparinuxRivaroxaban New 2010 product STA-Liquid anti-XaAssay of a Heparin family: drug monitoring Prenalytical variablesTIME OF BLOOD SAMPLING采血监测时间:CRITICALlinked to infusion mode & drug bioavailability与输液模式和生物利用度相关 Heparin family: drug monitoriCurat

29、ive UFH parenteral routesIV Heparin (heparin sodium肝素钠)Continuous infusion连续输液Sub-cutaneous Heparin皮下注射肝素 (heparin calcium肝素钙) 3 times a dayDifferences in Heparin bioavailability肝素不同的生物利用度(ideal scheme)Note: lower rate of recurrence in acute phase diseases for IV route* (continuous infusion = more s

30、table Heparin level / subcutaneous UFH) Theoretical Heparin level理论肝素水平Sub-cutaneous injectionTimeContinuous infusionAdapted from Parenteral Anticoagulants: -American College of Chest PhysiciansEvidence-Based Clinical Practice Guidelines (8th Edition) Chest June 2008 133:141S-159STheoretical targetedtherapeutic levelCurative UFH parenteral routes sample collectionat peak OR at the minimum protective levelHeparin level (IU/ml)injectionhours0 1 2 3 4 5 6 7 8 16 Sample