DOAC with prolonged PTT/INR

[faisal 2000]

I have Q
when I have to d/c oral anticoagulant (e.g Apixaban) if there is prolongation of PTT or INR with No bleeding? and when should I do doing mixing study and send the factors !?

lets say we have 2 patient

one of them on Apixiban with prolonged PTT (85)
another one on Apixiban with Prolonged INR (6)

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[BRCA123]

Why are you checking coags on DOAC?

 

[HemeOncHopeful19]

I try to check baseline coags if I can remember (although often by the time we are involved someone is already on them) otherwise I don't think you can really interpret them on a DOAC

 

[slruk]

DOACs can affect PT and PTT but not to this degree though typically, it's more typical to have mild alterations, like an INR of 1.3. INR 6 and PTT in the 80s is way off.

Find their baseline values if you can prior to when they were on AC. If they can tolerate being off AC and it would be safe to do so, you could hold the DOAC for 2 days and get everything, PT, PTT, mixing studies for both PT and PTT, some plasma saved/frozen if your institution does it. If this is the route you have to go to test off AC, then get appropriate factor levels too since you might as well make the most of that lab draw. Also should check for lupus anticoagulant and factor 12 as a cause of prolonged PTT.

To someone's point earlier, why were these checked? And it's not just a matter of discontinuing them for a number, you have to know what's going on. PTT in the 80s because they have a lupus anticoagulant, yeah that tracks, and is not an indication to stop.

 

[faisal 2000]

let's say

1- Non-valvular AF on Apix and INR is 6
what i will do is to do Mixing study and factor accordingly (unless fine to do Mixing study and factors while the patient on
anticoagulant) ??

2- the patient is male and has recurrent DVT on Rivaroxiban with high INR
depend if high more than 4 this is for me not explanined by Riva
i will do same as above but
if INR less than 4
i Will shift him to Apixiban since it is less than riva to prolonged PT

 

[bobsmith]

Why are you checking coags on DOAC?

To someone's point earlier, why were these checked? And it's not just a matter of discontinuing them for a number, you have to know what's going on

You still need to answer these questions

 

[HemeOncHopeful19]

I’m willing to assume this is a consult from ED/Hospitalist midlevel and the answer is “we don’t know”

 

[BRCA123]

let's say

1- Non-valvular AF on Apix and INR is 6
what i will do is to do Mixing study and factor accordingly (unless fine to do Mixing study and factors while the patient on
anticoagulant) ??

2- the patient is male and has recurrent DVT on Rivaroxiban with high INR
depend if high more than 4 this is for me not explanined by Riva
i will do same as above but
if INR less than 4
i Will shift him to Apixiban since it is less than riva to prolonged PT

1. ??? Don’t do mixing study? Apixaban is 5mg bid dosing.

2. No need to check INR. Just stop rivoraxaban and switch to apixaban.

 

[faisal 2000]

You still need to answer these questions

i get alot of these consult from Er, surgery
They all the time do these tests

 

[faisal 2000]

1. ??? Don’t do mixing study? Apixaban is 5mg bid dosing.

2. No need to check INR. Just stop rivoraxaban and switch to apixaban.

I don’t get it why you shift the patient to Apixaban? Depend on what?

 

[gutonc]

i get alot of these consult from Er, surgery
They all the time do these tests

Then just tell them that it doesn't matter and move on.

 

[BRCA123]

I don’t get it why you shift the patient to Apixaban? Depend on what?

I won’t shift to apixaban based on INR if thats what you are asking.

 

[HemeOncHopeful19]

Then just tell them that it doesn't matter and move on.

I get OPs frustration, you are basically being asked to take on the liability for any bleeding event from that point forward in the patient’s life if you do tell them it doesn’t matter

Edit: for this reason I really hate VTE/OAC consults which is unfortunate because they are actually one of the more interesting areas of benign Heme it feels like walking through a minefield in 2025 USA and I’d prefer to just never see one again if I could

 

[faisal 2000]

I won’t shift to apixaban based on INR if thats what you are asking.

yes i understand but why you wanna to shift to apxiaban?

 

[faisal 2000]

Then just tell them that it doesn't matter and move on.

I do not know but i think we have to get cut off numbers to do something regarding these high scary numbers not just move on