抗凝治療的實驗室監(jiān)測長城會議課件

1、1抗凝治療的實驗室監(jiān)測上海交通大學(xué)醫(yī)學(xué)院附屬瑞金醫(yī)院王學(xué)鋒1抗凝治療的實驗室監(jiān)測上海交通大學(xué)醫(yī)學(xué)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靜脈間接Xa抑制劑2002IIa口服直接凝血酶抑制劑2004AT + Xa + IIa(Xa IIa)低分子量肝素1980sII, VII, IX, X(Protein C,S)華法林1940sXa口服直接Xa抑制劑2008抗凝藥物發(fā)展史IIa靜脈

2、直接凝血酶抑制劑1990s3AT+ Xa + IIa普通肝素1930sAT + Xa靜OAT藥物個體差異性遺傳性因素:Hereditary resistance to warfarin 遺傳性華法林抵抗(rare)Race種族獲得性因素Variations in the metabolisms of vitamin K, OAT and coagulation factors 維生素K，口服抗凝藥和凝血因子的代謝差異Pathologies (e.g. renal insufficiency)疾?。I功能不全等）Age and weight 年齡和體重Drugs and diet 藥物和飲食OA

3、T藥物個體差異性遺傳性因素: AVK 監(jiān)測PT (1935):多種試劑缺乏統(tǒng)一標(biāo)準(zhǔn)室間差異大INR (1984):結(jié)果的標(biāo)準(zhǔn)化：統(tǒng)一使用ISI有所改善，然而 AVK 監(jiān)測PT (1935):The goal of the monitoring is to maintain the patient within a narrow therapeutic range 監(jiān)測目標(biāo)：維持病人PT在一個狹窄的治療范圍內(nèi) PT監(jiān)測OATApproximate therapeutic rangeRisk of thrombosisSafety / efficacy zoneRisk of bleedingPT

4、The goal of the monitoring is Therapeutic ranges有效濃度范圍Therapeutic ranges have been recommended in INR by different representative groups 不同的機(jī)構(gòu)推薦使用INR作為治療范圍的監(jiān)測指標(biāo)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有效濃度范圍TheraTherapeutic rangesOAT適應(yīng)證及有效濃度范圍適用于需長期持續(xù)抗凝的患者 Therapeutic rangesOAT適應(yīng)證及有效濃度CAP survey 2007 CG-2CSame reagent / Different instruments00,20,40,60,811,2ABCDEFGHIJKLMINR00,511,52

6、2,533,5ABCDEFGHIJKLMINRINR 監(jiān)測- OATCAP survey 2007 CG-2CSame reag10肝素治療的實驗室監(jiān)測問題10肝素治療的實驗室監(jiān)測問題11肝素與低分子量肝素肝素誘導(dǎo)的血小板減少癥肝素抵抗常見問題11肝素與低分子量肝素肝素誘導(dǎo)的血小板減少癥肝素抵抗常見問題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 監(jiān)測所有患者主要副作用:

8、 抗凝效果延遲: 血栓進(jìn)展或復(fù)發(fā)過度抗凝: 增加出血風(fēng)險嚴(yán)重出血頻率UFH : 5 %HIT (Heparin Induced Thrombocytopenia)WHY？14UFH 監(jiān)測所有患者WHY？15LMWH 監(jiān)測預(yù)防給藥:不需要治療給藥:首次給藥48小時后的劑量調(diào)整特殊情況: 體重過輕或過重 (160 Kg)腎功能損害 (creatinine clearance 30 mL/min)妊娠(3rd quarter)長期治療新生兒 ( 2 months) or兒童 出血者效果不佳者15LMWH 監(jiān)測預(yù)防給藥: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，迅速發(fā)揮作用無法預(yù)測劑量反應(yīng)結(jié)合血漿蛋白 結(jié)合內(nèi)皮細(xì)胞，巨噬細(xì)胞和血小板加強(qiáng)清除清除率差異 12倍高分子量排出快17UFHChest. 2004;126:188S-203S18UFH廣泛使用，不正確使用出血風(fēng)險大藥物相關(guān)問題 出血 HIT需要多次

10、劑量調(diào)整，反復(fù)實驗室監(jiān)測開始每6h,穩(wěn)定后每天一次輸注對側(cè)肢體采血Pharmacotherapy. 2004;24:146S-155S.Arch Pathol Lab Med. 1998;122:782-798.18UFH廣泛使用，不正確使用出血風(fēng)險大Pharmacoth19How to Monitor?aPTTHeparin Assay19How to Monitor?aPTTHeparin A20aPTT監(jiān)測優(yōu)點(diǎn)最常用便宜TAT時間短缺點(diǎn)治療范圍與試劑和批號有關(guān)普通凝血檢測指標(biāo)，肝素檢測非特異只能用于 UFH, 不適合LMWH20aPTT監(jiān)測優(yōu)點(diǎn)21aPTT 試劑變異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 試劑變異ReagentaPTT Range C22aPTT延長原因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延長原因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無法準(zhǔn)確預(yù)測肝素水平不同試劑間一致性 47%不到治療水平的 aPTT 68.5% 達(dá)到治療的肝素水平Arch Intern Med. 1997;157:2475.25aPTT無法準(zhǔn)確預(yù)測肝素

15、水平Arch Intern Me26aPTT vs. Heparin Assay持續(xù)aPTT不到治療水平與VTE的發(fā)生或復(fù)發(fā)有關(guān):Clin Appl Thromb Hemost. 1997:3:S64-67.24 h內(nèi)治療濃度達(dá)標(biāo):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持續(xù)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磺達(dá)肝睽鈉(fondaparinux)外科術(shù)后內(nèi)科患者妊娠婦女4lOd1114d14d女性男性病情重(如腫瘤或敗血癥)和高齡患者的風(fēng)險高黑人白人 牛源豬源41臨床特點(diǎn)危險因素 42臨床特點(diǎn)血小板減少(診斷的先決條件)514 d,50109L80109L(100109L)，或較基礎(chǔ)值下降50，且通常可在停用肝素l周后恢復(fù)正常最近曾接受過肝素治療且體內(nèi)存在抗肝素-PF4抗體，則再次接觸肝素時血小板減少可在數(shù)分鐘內(nèi)出現(xiàn)無血小板減少并不能排除HIT診斷HIT相關(guān)的血栓事件可在血小板

18、減少之前出現(xiàn)42臨床特點(diǎn)血小板減少(診斷的先決條件)434344診 斷4T診斷積分系統(tǒng)44診 斷4T診斷積分系統(tǒng)45實 驗 診 斷45實 驗 診 斷46實 驗 診 斷46實 驗 診 斷47實 驗 診 斷血小板聚集實驗的敏感性大于90，特異性范圍為77100%47實 驗 診 斷血小板聚集實驗的敏感性大于90，特48實 驗 診 斷48實 驗 診 斷49抑制試驗實 驗 診 斷49抑制試驗實 驗 診 斷50實 驗 診 斷50實 驗 診 斷51實 驗 診 斷51實 驗 診 斷52實 驗 診 斷52實 驗 診 斷53診 斷53診 斷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 市場上的新抗凝藥物rivaroxaban(XARELTO)apixaban (ELIQUIS)dabigatran (PRADAXA)XaIIaTF/VIIaXIXIXaVIIIaVaIIFibrinFibrinogenAdapted from Bates SM, Weitz

20、 JI. Br J Haematol 2006; 134: 3-19目前市場上的3種口服，單一劑量，無需監(jiān)測的抗凝藥物：兩種直接Xa因子抑制劑一種直接IIa因子抑制劑 市場上的新抗凝藥物rivaroxaban(XARELTO實驗室監(jiān)測或無需實驗室監(jiān)測實驗室監(jiān)測或無需實驗室監(jiān)測實驗室監(jiān)測或無需實驗室監(jiān)測無需監(jiān)測但需要檢測抗凝活性者特殊人群敏感人群，老年人，腎功能受損，肥胖患者威脅生命的情況出血，藥物過量實驗室監(jiān)測或無需實驗室監(jiān)測無需監(jiān)測可以使用哪些方法全球通用方法PTAPTT特殊方法依賴于抗凝靶點(diǎn)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制備方法Anti-Xa / anti-IIa ratioMean molecular weightaPTT 延長Danaparoid sodium (Orgaran)動物腸粘膜：硫酸乙酰肝素（84），硫酸皮膚素（12） 206,500 D-Dalteparin (Fragmin)亞硝酸解聚2.55,000 D+/-Enoxaparin (L

27、ovenox, Clexane)芐基+堿性解聚3.64,500 D+/-Nadroparin (Fraxiparin)亞硝酸解聚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-新型胃腸外藥物Agent制備方法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 一步競爭法“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采血監(jiān)測時間:CRITICALlinked to infusion mode & drug bioavailability與輸液模式和生物利用度相關(guān) Heparin family: drug monitoriCurat

29、ive UFH parenteral routesIV Heparin (heparin sodium肝素鈉)Continuous infusion連續(xù)輸液Sub-cutaneous Heparin皮下注射肝素 (heparin calcium肝素鈣) 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理論肝素水平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