Background: Best practices for monitoring of both old and newer anticoagulants rely on a combination of published research, pharmaceutical companies’ drug approval applications and package inserts, expert opinion, and clinical experience. Clinical laboratories now face a constantly changing environment that challenges the ability of centers to provide timely, accurate, and appropriate guidance for clinical care.

Aims: To summarize major challenges in anticoagulation management at an academic medical center during a two decade period.

Methods: Review of changes in laboratory testing, including in reagents, in the context of anticoagulation management, through examination of the changes in test procedures and recommendations for dose adjustment during the study period. Comparison of these procedures and recommendations with conclusions of published research, pharmaceutical company recommendations, and the guidance of expert organizations.

Results: Major challenges in laboratory management of anticoagulation experienced at an academic medical center have included making recommendations on
(I) monitoring of intravenous therapeutic heparin anticoagulation, including challenges related to
(a) changes in activated partial thromboplastins,
(b) changes in the ability to offer aPTT and anti-Factor Xa activity assays,
(c) ambiguity regarding target values for anti-Factor Xa using reagents with or without exogenous antithrombin, and
(d) limited information on appropriate anticoagulation in pediatrics (including patients receiving extracorporeal membrane oxygenation;
(II) monitoring intravenous antithrombin medications in a manner that would not heighten the likelihood of adverse events;
(III) anticoagulation monitoring in the setting of lupus anticoagulant; and
(IV) monitoring of direct acting oral anticoagulants when such monitoring is not recommended by the pharmaceutical manufacturers.

Conclusions: A multidisciplinary team approach of the coagulation laboratory, clinical hemaotologists (both adult and pediatric), hospital pharmacists, and transfusion medicine specialists has enabled challenges in anticoagulation monitoring to be addressed, even when randomized controlled trials for the described challenges may not have been available to guide such decisions.

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ISTH Congress Abstracts - https://abstracts.isth.org/abstract/challenges-in-anticoagulation-management-at-an-academic-medical-center-20-years-of-clinical-observations/