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Saturday, December 3, 2011

COAGULATION CORNER: DECEMBER 2011

COAGULATION 2011:  YEAR IN REVIEW

It is hard to believe another year has gone by, as I get older time passes much more quickly. The end of a year is time that we reflect what has happened, review what has been positive or negative and try to rejuvenate to begin the next year.

So what has 2011 brought us in the coagulation world? Where have the advances been, what have been the biggest issues, and what is the future? I think the hottest topic is anticoagulation. For so many years there have been limited options, and now the field has exploded. Have heparin, and warfarin out lived there time? Will they become the 8 track players of coagulation? (for those of you who don’t know what an 8 track player is- google it) I am not about to take that stand. Not until we have more information on the new anticoagulants and how to reverse them, and more importantly how to monitor them. If we have learned nothing else this year, it is that the oral direct thrombin inhibitors and oral Xa inhibitors are not a perfect science. They can place patients at a risk for bleeding, additionally, how is one to know if patients are complying with dosing? It is an oral anticoagulant- compliance is a big issue- and there is no way to check what a patient has on board.

What has happened to thrombin generation? Just two years ago, every other abstract looked at thrombin generation. Okay, so the assay is not ready for prime time, so is this the tape cassette of coagulation, was good for awhile, but we know that something better is out there? Do you know that an APTT only measures 2% of thrombin generated? Thrombotic events are on the rise, we need to not only be able to diagnose patients, but understand who is at risk and focus on prevention.

Ah, platelets, let us not forget out little friends- and maybe learn that they do have a nucleus of sort- and that they roll along, as they gather together! Another huge issue, does aspirin really help? Should dual anti-platelet therapy be used? What about genetic mutations? Increasing doses to overcome them works, but can put a patient at a risk for bleeding- wouldn’t it be easier to test patients for the mutations? Cost, yes it costs, but again, we have the knowledge available, shouldn’t we put it to good use and improve patient outcomes?

Next issue, pregnancy and thrombosis, big issue- why do we not screen women? Why in this day in age, when we have the technology do we still wait for women to have 3 miscarriages before we look for a cause for thrombosis? Again the cost, how much is the cost of treating patients after a miscarriage versus a thrombotic workup? We have so many synergistic issues that put women at risk- pregnancy itself is a thrombotic state, add thyroid disease, homocysteine, folic acid levels, and I haven’t even mentioned genetic mutations- MTHFR, Prothrombin mutation, FV Leiden, PAI-1, as well as sedentary life styles and obesity. Again, technology is there, shouldn’t we use it? On the flip side, excess bleeding during menstruation- your grandmother, your mother, your daughter. This is a pattern, it is not acceptable to say we are all bleeders- when it impacts your quality of life- don’t be a martyr- ask questions- ask to be tested, you might have Von Willebrands disease.

So, that is my soap box issues for the year 2011. I can’t close out the year without some type of holiday cheer- so here is my version of:

Walking in a Winter Wonderland- or
Working with the Waterfall Cascade-

Factors activate are you ready
In a vessel coagulation is steady
But wait there’s a cut-
Platelets do your stuff
Working with the Waterfall Cascade

Gone away is the bleeding
Thrombin is here that’s what your needing
To form a blood clot
As fibrin gets hot
Working with the Waterfall Cascade

But wait that clot is getting much larger
Heparin needs to be given right away
Should we give unfractionated heparin
Or will lovenox be the drug to save the day?

Later on, we’ll switch to warfarin
As we check the PT/INR range to be in
To ensure the dose we gave
Will not be too grave-
Working with the Waterfall Cascade

In the case we need to use another
Now we can give dabigatran
Twice a day to inhibit thrombin
Except that there is no monitoring on hand

When it works, ain’t it thrilling
Preventing clots and halting bleeding
We’ll test and monitor
In the coag lab
Working with the Waterfall Cascade!

Have a wonderful Holiday season, all the best and happiness in 2012-
Be proud of what you do, your patients need you!

Donna Castellone

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About the Author

Donna Castellone,  MS, MT(ASCP)SH

Donna Castellone,
MS, MT(ASCP)SH

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