Target Drug-Calibrated Anti-Xa Activity Assays and Expected Peak-Trough Levels in an Asian Population: A Multicenter Study

Abstract

Background For patients taking factor Xa (FXa) inhibitors who have life-threatening bleeding, emergency surgery, drug interactions, etc., a rapid and precise assay is needed to monitor for potential medication failure, to assess safety during periprocedural anticoagulation management, and to manage the care of chronically anticoagulated patients. Anti-factor Xa (anti-Xa) activity assays have been recommended in guidelines, but the evaluation of different calibrations of anti-Xa activity assays and the data on the recommended range are still limited, especially in the Asian population. Methods This is a nationwide multicenter methodology exploratory study in an Asian population, including nine hospitals from Beijing, Shanghai, Liaoning, Shandong, Jiangsu, Anhui, Henan, Chongqing, and Fujian. A total of 485 healthy volunteers and 219 patients taking rivaroxaban or apixaban (single dose) were enrolled in the study. High-performance liquid chromatography-tandem mass spectrometry (HPLC-MS) was employed to detect plasma rivaroxaban and apixaban. The prothrombin time (PT), activated partial thromboplastin time (APTT), and levels of anti-Xa activity were tested as pharmacodynamic parameters in plasma samples. We evaluated the correlation of anti-Xa activity and blood concentration via HPLC-MS, and then compared the two methods of target drug-calibrated and low-molecular-weight heparin (LMWH)-antithrombin-calibrated anti-Xa activity. Correlations between variables were examined using Pearson's correlation analysis. Logistic regression was applied to evaluate significant differences in anti-Xa activity and blood concentration, using models adjusted by baseline characteristics. Results The results suggested anti-Xa activity had better correlation with blood concentrations of apixaban and rivaroxaban than APTT and PT (p < 0.001). Target drug-calibrated anti-Xa activity had better correlation with HPLC-MS results at every dose level and blood collection time (p < 0.001). The expected concentrations (ng/mL) derived from rivaroxaban-calibrated assays of rivaroxaban 10 mg, 15 mg, and 20 mg were about 210, 330, and 270 at peak concentrations, and 28, 44, and 58, respectively, at the trough concentrations. Conclusions In this study, we confirm that target drug calibration of anti-Xa activity is a better quantitative detection method for oral direct FXa inhibitors than LMWH-calibrated anti-Xa activity in clinical practice, and expected peak-trough levels are recommended for the Asian population.