November 2010 Cheat Sheet

Mirnaibarra” in El Paso asks, “Do you recommend the 4:1 mix to be used routinely? Also, what is the most common and preferred way of interpreting mixing studies correction; percent correction, a percent of PNP or the Rosner Index?
George answers that most labs use the 1:1 mix of patient plasma and NP for initial mixing studies, occasionally using a 3:1 or 4:1 mix when a thrombotic picture suggests LA but the 1:1 mix corrects. Dr. Larry Brace also advocates for the 1:1 mix on the grounds that a lupus anticoagulant-sensitive PTT reagent is at least as likely to detect lupus anticoagulant as is a 4:1 mix.
George posted a Quick Question in June polling our participants on their criteria for mixing study correction. The majority of people use correction to within 5 seconds of the normal control plasma. George advocates for correction within 10%, using the Rosner index, whereas Dr. Dorothy Adcock of Esoterix Coagulation requires correction to within the upper limit of the normal range.

Steve Duff of Precision BioLogic alerts us to a new recall of unfractionated heparin posted by the US FDA on October 27, 2010. The supplier, Scientific Protein Laboratories, in testing retained crude heparin lots revealed traces of oversulfated chondroitin sulfate. This is the same problem that created a public health risk in 2008.

McDowekm” performs anti-Xa heparin testing on a hybrid curve using Stago’s Rotachrom reagent. If a specimen is lipemic, it can falsely raise the anti-Xa result. Can lipemic specimens be ultra-centrifuged to obtain a more accurate Anti-Xa result?
George responds that it would be helpful to review the data that indicate lipemia is raising the anti-Xa results. When performing the Rotachrom assay according to published protocols using the hybrid curve, the original specimen reaches a final dilution, counting diluents and reagents, of 1:22. Given this dilution, and according to the manufacturer’s package insert, interference will occur only when the original triglyceride concentration rises to above 360 mg/dL. Also, lipemia would be expected to reduce, not raise the anti-Xa result. This post generated three comments.

Stacy Askvig at the University of North Dakota Medical Center asks, “I do only PTs and PTTs , and my references seem to give me conflicting interpretations. Our patient has a prolonged PTT and DRVV, both are shortened in mixing studies:
PTT-LA 107 seconds, mix 79.5 (reference interval 0-50)
DRVV 73 seconds, mix 56.7 (reference interval 0-44)
George responds the PTT and DRVVT are both prolonged and do not adequately correct in the mixing studies. This is presumptive evidence for the presence of a lupus anticoagulant (LA ). To confirm an LA Stacy would need to next perform a phospholipid neutralization step using a high phospholipid reagent.

Skierktc” wonders if anyone screens with the TT plus protamine sulfate to rule out heparin in the specimen. If yes, what is their policy for continuation of the study?
George responds that when you encounter a prolonged PTT that is not corrected by NP , perform a TT to determine if the patient is receiving heparin. Heparin will prolong the TT from its normal mean to 40 seconds or longer. Once you have concluded heparin is present, treat the specimen with Hepsorb or Hepzyme, then repeat the mixing study.

On 11/19/10, Pfizer and Bristol Myers Squibb discontinued the APPRAISE-2 phase 3 trial of Apixiban in high-risk patients with acute coronary syndrome. Apixiban bleeding risks were not offset by its antithrombotic benefit in the high-risk patient population. At least two trials appear to show that Apixiban, which is a direct anti-Xa oral antithrombotic, is effective at stroke prevention in atrial fibrillation. The oral direct anti-thrombin drug Dabigatran (Pradaxa, Boehringer-Ingelheim) was released by the US FDA for stroke prevention in October.

We recently posted a brief survey asking laboratory scientists to characterize the sensitivity of their “routine” APTT assay for LA. This is a new three-question follow-up survey for physicians. The APTT is used to monitor anticoagulant therapy, screen for coagulation factor deficiencies as a means to predict risk of bleeding, and to screen for LA , which may be associated with thrombosis and or recurrent miscarriage. A number of APTT reagents are available that are highly, moderately, or minimally sensitive to lupus anticoagulants. We propose to learn which of these three applications of the APTT are of most importance to clinicians, and to determine clinician understanding of APTT reagent LAC sensitivity. Investigators are Ellinor Peerschke, PhD, Elizabeth Van Cott, MD,Dorothy (Dot) Adcock-Funk, MD, and Marisa B. Marques, MD. Ankush Randhawa and George Fritsma assisted with survey development.

Dan Hood asks, “What testing do you recommend for Plavix effect for patients preoperatively?”
George indicates that Plavix suppresses platelets by blocking ADP receptors. The reference method for Plavix effect is platelet aggregometry using ADP as the agonist. However, if your laboratory is not performing aggregometry, you may want to use the Accumetrics VerifyNow P2Y12 or the Helena PlateletWorks ADP Kit. Further, DiaPharma distributes the Multiplate 5.0 Analyzer, which is currently under FDA review. Joe Lamband Donna Lawler add comments recommending the Thromboelastograph.

G Pihan from Beth Israel Deaconess asks, “What is the incidence of false positive hexagonal phospholipid neutralization tests in the presence of a strong (400-800 BU ) factor VIII inhibitor?”
George answers the hex-phase phospholipid is the most specific platelet membrane surrogate for identifying lupus anticoagulants when testing in a PTT system. There are no data published on the incidence of false positives, although it is possible that a high-titer factor VIII inhibitor could cross-react in the Staclot-LA system.
The ISTH requires that we use at least two parallel testing systems to confirm LA , and most of us use a PTT-based kit and a dilute Russell viper venom (DRVVT )-based kit. In instances when the DRVVT result is negative but the PTT-based hex-phase phospholipid result is positive for LA , the lab should follow up with a factor VIII assay to rule out factor VIII deficiency or a factor VIII inhibitor.