RESUMO
BACKGROUND: Routine monitoring of direct oral anticoagulant (DOAC) levels is not recommended but may be useful in certain clinical situations. There is a knowledge gap regarding the clinical use of DOAC levels in Australian hospitals. AIMS: To evaluate the clinical settings, indications and changes to anticoagulant management associated with DOAC levels in a tertiary hospital in Northern Tasmania, Australia. METHODS: Patients with one or more DOAC levels (dabigatran, rivaroxaban or apixaban) requested between January 2017 and December 2022 were identified. Retrospective chart review was performed to evaluate the clinical settings, indications, adequacy of request information and changes to clinical management associated with the measurement of DOAC levels. RESULTS: One hundred and twenty-nine DOAC measurements (54 rivaroxaban, 66 apixaban and nine dabigatran) were performed in 98 patients between January 2017 and December 2022. Annual requests for DOAC levels increased significantly between 2017 and 2019 and remained stable between 2020 and 2021 but declined in 2022. Overall, the most common indication for a DOAC level was renal impairment, followed by bleeding and recurrent thrombosis. Approximately 25% of requests were for acute bleeding with a reversal/haemostatic agent given in 45% of patients, while 10% were prior to urgent surgery. Measurement of DOAC levels was associated with a change in management in 50% of cases. 10% of requests did not specify anticoagulant history. CONCLUSION: Trends in requests for DOAC levels have changed over time. Clinician education regarding the importance of providing specific anticoagulant history is essential. Future prospective studies investigating the clinical utility of DOAC levels in different clinical settings are needed.
Assuntos
Dabigatrana , Pirazóis , Piridonas , Rivaroxabana , Humanos , Estudos Retrospectivos , Tasmânia , Feminino , Masculino , Idoso , Pirazóis/sangue , Pirazóis/uso terapêutico , Pirazóis/administração & dosagem , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Rivaroxabana/sangue , Rivaroxabana/uso terapêutico , Rivaroxabana/administração & dosagem , Piridonas/sangue , Piridonas/uso terapêutico , Piridonas/administração & dosagem , Dabigatrana/sangue , Dabigatrana/uso terapêutico , Dabigatrana/administração & dosagem , Hemorragia/sangue , Monitoramento de Medicamentos/métodos , Administração Oral , Inibidores do Fator Xa/sangue , Inibidores do Fator Xa/uso terapêutico , Inibidores do Fator Xa/administração & dosagem , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Trombose/sangue , Trombose/prevenção & controleRESUMO
Bone marrow fibrosis in myelodysplastic syndromes (MDS) has been associated with poor outcome. However, these studies were conducted prior to the widespread use of azacitidine in the management of MDS. Our study aimed to assess whether treatment with azacitidine ameliorates the inferior outcome in MDS with fibrosis. A retrospective study of all patients diagnosed with MDS and treated with azacitidine over 3 years in two institutions was performed. A total of 21 patients were included in this study. Approximately half of these had moderate to severe bone marrow fibrosis at the start of treatment with azacitidine. The median overall survival was 34 months in patients with non-fibrotic bone marrow compared to 14 months in patients with fibrotic marrow (p=0.0007). Median event-free survival was 26 months versus 12 months (p=0.0027) in patients with non-fibrotic and fibrotic marrow, respectively. In multivariate analysis, bone marrow fibrosis was an independent factor in overall survival. Transfusion requirement was not different between the two groups. Despite the small sample size, we observed a worse outcome in azacitidine treated patients with MDS and fibrotic marrow. We suggest a prospective larger study to confirm the above finding.
Assuntos
Síndromes Mielodisplásicas , Mielofibrose Primária , Antimetabólitos Antineoplásicos/uso terapêutico , Azacitidina/uso terapêutico , Fibrose , Humanos , Síndromes Mielodisplásicas/diagnóstico , Síndromes Mielodisplásicas/tratamento farmacológico , Estudos Prospectivos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Drug-specific anti-Xa chromogenic assays are recommended for measurement of direct anti-Xa inhibitor levels but are not routinely available in many institutions. We performed a prospective study to determine: (1) the relationship between low molecular weight heparin (LMWH) calibrated anti-Xa measurements and apixaban or rivaroxaban levels measured using drug-specific anti-Xa assays and, (2) if a LMWH calibrated anti-Xa assay can be used to detect clinically significant apixaban or rivaroxaban levels. Haematology outpatients on rivaroxaban or apixaban for at least 72 h were recruited for this study. Anti-Xa LMWH assay was performed using the Innovance Heparin Anti-Xa kit/calibrator. Drug-specific levels were determined using STA-Liquid anti-Xa kit/STA-Apixaban or STA-Rivaroxaban calibrators. Serial dilutions with pooled normal plasma were performed for specimens with anti-Xa LMWH activity greater than 1.50 ng/mL to obtain anti-Xa levels within the reportable range (0.10-1.50 ng/mL) and multiplied by the dilution factor to determine actual anti-Xa level. Seventy-five (39 rivaroxaban, 36 apixaban) specimens from 67 patients (mean age 60.3 years; 53.3% males) were available for analysis. Rivaroxaban levels ranged from <25 to 500 ng/mL while apixaban levels ranged from <20 to 236.1 ng/mL. For both rivaroxaban and apixaban, there was linear and good correlation (R2 = 0.96) between direct oral anticoagulants and anti-Xa LMWH levels. Using the correlation equation from our data, a rivaroxaban concentration of 50 ng/mL [International Society on Thrombosis and Haemostasis (ISTH) threshold for consideration of antidotes in bleeding patients] and 30 ng/mL (ISTH threshold for consideration of reversal agents prior to interventions), corresponds to anti-Xa LMWH levels of 0.50 and 0.35 IU/mL, respectively. For apixaban the corresponding anti-Xa LMWH levels were 0.35 and 0.20 IU/mL, respectively. In conclusion, LWWH calibrated anti-Xa assay can be used in emergency situations to screen for clinically significant apixaban or rivaroxaban levels when drug-specific calibrators are not available.
Assuntos
Heparina de Baixo Peso Molecular , Rivaroxabana , Anticoagulantes/farmacologia , Testes de Coagulação Sanguínea , Inibidores do Fator Xa , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Piridonas , Rivaroxabana/farmacologiaAssuntos
Dor Abdominal/etiologia , Anemia Hemolítica/diagnóstico , Síndrome de Budd-Chiari/diagnóstico , Hemoglobinúria Paroxística/diagnóstico , Dor Abdominal/diagnóstico , Adulto , Anemia Hemolítica/complicações , Anticorpos Monoclonais Humanizados/uso terapêutico , Anticoagulantes/uso terapêutico , Síndrome de Budd-Chiari/complicações , Síndrome de Budd-Chiari/tratamento farmacológico , Inativadores do Complemento/uso terapêutico , Quimioterapia Combinada , Ferritinas/análise , Hemoglobina A/análise , Hemoglobinúria Paroxística/tratamento farmacológico , Hemoglobinúria Paroxística/etiologia , Hemólise , Hepatomegalia/diagnóstico , Humanos , Masculino , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento , Varfarina/uso terapêuticoAssuntos
Anticorpos Monoclonais Humanizados/farmacologia , Doença de Hodgkin/patologia , Linfadenopatia/tratamento farmacológico , Linfadenopatia/patologia , Adulto , Progressão da Doença , Doença de Hodgkin/diagnóstico , Humanos , Linfonodos/patologia , Linfadenopatia/diagnóstico , Masculino , Resultado do TratamentoAssuntos
Anemia Perniciosa/diagnóstico , Hidroxocobalamina/uso terapêutico , Complexo Vitamínico B/uso terapêutico , Anemia Perniciosa/complicações , Anemia Perniciosa/tratamento farmacológico , Anemia Perniciosa/fisiopatologia , Atenção , Índices de Eritrócitos , Fadiga/etiologia , Fadiga/fisiopatologia , Humanos , Injeções Intramusculares , Diagnóstico Ausente , Doenças do Sistema Nervoso Periférico/etiologia , Doenças do Sistema Nervoso Periférico/fisiopatologia , Deficiência de Vitamina B 12/complicações , Deficiência de Vitamina B 12/diagnóstico , Deficiência de Vitamina B 12/tratamento farmacológico , Deficiência de Vitamina B 12/fisiopatologiaAssuntos
Macroglobulinemia de Waldenstrom/diagnóstico , Doenças de von Willebrand/diagnóstico , Idoso , Diagnóstico Diferencial , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Masculino , Macroglobulinemia de Waldenstrom/complicações , Macroglobulinemia de Waldenstrom/terapia , Doenças de von Willebrand/complicações , Doenças de von Willebrand/terapiaAssuntos
Cobre/deficiência , Deficiências Nutricionais , Degeneração Hepatolenticular/complicações , Pancitopenia , Adulto , Células da Medula Óssea/patologia , Cobre/sangue , Cobre/uso terapêutico , Deficiências Nutricionais/complicações , Deficiências Nutricionais/diagnóstico , Deficiências Nutricionais/tratamento farmacológico , Feminino , Hemoglobinas/análise , Humanos , Pancitopenia/diagnóstico , Pancitopenia/etiologia , Zinco/sangueAssuntos
Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Anomalia de Pelger-Huët/etiologia , Baço/patologia , Condicionamento Pré-Transplante/efeitos adversos , Transplante Homólogo/efeitos adversos , Adulto , Transplante de Células-Tronco Hematopoéticas/métodos , Humanos , Masculino , Anomalia de Pelger-Huët/patologia , Condicionamento Pré-Transplante/métodos , Transplante Homólogo/métodosAssuntos
Erros de Diagnóstico/prevenção & controle , Proteína da Hemocromatose/genética , Hemocromatose , Fígado , Flebotomia/métodos , Adulto , Diagnóstico Diferencial , Ferritinas/sangue , Hemocromatose/diagnóstico , Hemocromatose/genética , Hemocromatose/fisiopatologia , Hemocromatose/terapia , Humanos , Sobrecarga de Ferro/diagnóstico , Sobrecarga de Ferro/genética , Fígado/diagnóstico por imagem , Fígado/patologia , Testes de Função Hepática/métodos , Masculino , Mutação , Prognóstico , Avaliação de Sintomas/métodos , Transferrina/análiseAssuntos
Adenocarcinoma/tratamento farmacológico , Antineoplásicos/uso terapêutico , Neoplasias Colorretais/tratamento farmacológico , Leucemia Promielocítica Aguda/diagnóstico , Segunda Neoplasia Primária/diagnóstico , Mielofibrose Primária/diagnóstico , Doença Aguda , Adenocarcinoma/terapia , Antineoplásicos/efeitos adversos , Capecitabina/efeitos adversos , Capecitabina/uso terapêutico , Quimiorradioterapia , Neoplasias Colorretais/terapia , Feminino , Humanos , Idarubicina/uso terapêutico , Leucemia Promielocítica Aguda/tratamento farmacológico , Leucemia Promielocítica Aguda/etiologia , Leucemia Promielocítica Aguda/patologia , Pessoa de Meia-Idade , Segunda Neoplasia Primária/tratamento farmacológico , Segunda Neoplasia Primária/etiologia , Segunda Neoplasia Primária/patologia , Compostos Organoplatínicos/efeitos adversos , Compostos Organoplatínicos/uso terapêutico , Oxaliplatina , Pancitopenia , Mielofibrose Primária/tratamento farmacológico , Mielofibrose Primária/etiologia , Mielofibrose Primária/patologia , Indução de Remissão , Tretinoína/uso terapêuticoRESUMO
Multiple myeloma and Paget's disease of bone show certain similarities such as increased osteoclastic activity and predilection to the axial skeleton. However, pathological and radiological changes of the bones are distinctive between multiple myeloma and Paget's disease of bone. This case report describes a patient who had a concomitant diagnosis of multiple myeloma and Paget's disease evidenced from bone marrow biopsy. Such a co-existence is rare, with only a few cases reported so far.
Assuntos
Medula Óssea/patologia , Mieloma Múltiplo/diagnóstico , Osteíte Deformante/diagnóstico , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Biópsia , Bortezomib/administração & dosagem , Dexametasona/administração & dosagem , Difosfonatos/administração & dosagem , Humanos , Imidazóis/administração & dosagem , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/tratamento farmacológico , Mieloma Múltiplo/patologia , Osteíte Deformante/tratamento farmacológico , Osteíte Deformante/patologia , Resultado do Tratamento , Ácido ZoledrônicoRESUMO
Chronic myeloid leukaemia is a myeloproliferative neoplasm characterised by granulocytic hyperplasia in the bone marrow and the presence of a specific cytogenetic abnormality known as Philadelphia chromosome with fusion of breakpoint cluster region (BCR) and ableson (ABL) genes. Retinopathy is a rare sight-threatening complication of chronic myeloid leukaemia, which occurs due to leucostasis in retinal blood vessels. We report a case of a patient who presented with visual impairment due to leucostasis, who was successfully managed by leucapheresis along with BCR-ABL tyrosine kinase inhibitor.
Assuntos
Leucaférese , Leucemia Mielogênica Crônica BCR-ABL Positiva/complicações , Transtornos da Visão/etiologia , Transtornos da Visão/terapia , Dasatinibe/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Cromossomo Filadélfia , Inibidores de Proteínas Quinases/uso terapêuticoRESUMO
Cytogenetic abnormalities occur in approximately 60% of newly diagnosed patients with acute myeloid leukaemia (AML) and are useful in the risk stratification of AML. Translocation between chromosomes 8 and 21-t(8;21)-(q22;q22.3), which carries a favourable prognosis, is found in approximately 5% to 10% of all patients with AML. Additional chromosomal abnormalities have been described in patients with AML with t(8;21), which may impact on the favourable prognosis. We report a patient who had AML with t(8;21)(q22;q22.3) and loss of the X chromosome.
Assuntos
Cromossomos Humanos Par 21 , Cromossomos Humanos Par 8 , Cromossomos Humanos X , Leucemia Mieloide Aguda/genética , Monossomia , Translocação Genética , Adulto , Aberrações Cromossômicas , Feminino , Humanos , Cariotipagem , Leucemia Mieloide Aguda/complicações , Leucemia Mieloide Aguda/diagnóstico , PrognósticoAssuntos
Ataque Isquêmico Transitório/etiologia , Púrpura Trombocitopênica Trombótica/diagnóstico , Proteínas ADAM/genética , Proteínas ADAM/imunologia , Proteínas ADAM/metabolismo , Proteína ADAMTS13 , Anemia Hemolítica/etiologia , Autoanticorpos , Diagnóstico Diferencial , Marcadores Genéticos , Humanos , Masculino , Pessoa de Meia-Idade , Troca Plasmática , Púrpura Trombocitopênica Trombótica/complicações , Púrpura Trombocitopênica Trombótica/terapiaRESUMO
Primary hepatic lymphoma (PHL) is a very rare sub-type of non-Hodgkin's lymphoma and hepatitis C infection may be a contributory factor. The association of hepatitis C infection and PHL causes difficulties in management since safety of rituximab in such situations is unclear due to lack of evidence. The role of anti-viral therapy in combination with chemotherapy is also uncertain. We describe the diagnostic and therapeutic challenges posed by a patient who was diagnosed with PHL and concurrent hepatitis C infection.