for their interest in the Austrian interdisciplinary consensus statement on diagnosis and treatment of traumatic brain injury (TBI) patients on oral anticoagulants
November 26, 2021
for their interest in the Austrian interdisciplinary consensus statement on diagnosis and treatment of traumatic brain injury (TBI) patients on oral anticoagulants. 91% of rivaroxaban could be removed from the blood during 1?h use of CytoSorb . This new therapy could perhaps complement the use of the antidote andexanet alfa, particularly if the antidote is not immediately available. In conclusion, we believe that studies comparing the two strategies (sorbents versus monoclonal antibodies) are urgently needed and that the use of CytoSorb to remove NOACs and anti-platelet agents in order to restore normal coagulation and to stop bleeding would be a very useful addition to the information presented in the Austrian recommendations. Authors response Herbert Sch?chl, Marion Wiegele, Eva Schaden To the editor We would like to thank Honore et al. for their interest in the Austrian interdisciplinary consensus statement on diagnosis and treatment of traumatic brain injury (TBI) patients on oral anticoagulants. The author state that bleeding patients on ticagrelor and non-vitamin K antagonist oral anticoagulants (NOACs) might benefit from extracorporeal removal of these drugs using CytoSorb? haemoperfusion (CHP). Indeed, in emergency open-heart surgery CHP of ticagrelor and rivaroxaban resulted in reduced bleeding complications and less drainage volume compared to a historical control group . Neither platelet transfusion nor desmopressin has been proven to be efficient in ticagrelor-associated bleeding. An in vitro study revealed that CHP removed ?99% of ticagrelor from human blood samples within 3?h . Albumin represents an alternative approach to bind ticagrelor. An experimental study using high-dose 42-(2-Tetrazolyl)rapamycin albumin spiking of blood samples containing ticagrelor resulted in a significant improvement of platelet function . This might be considered a 42-(2-Tetrazolyl)rapamycin less invasive and more rapid option compared to CHP. The role of CHP as an effective and easy to use alternative for NOAC removal in major bleeding is currently unproven. Experimental data revealed that within 1?h of CHP, 91.6% of rivaroxaban was effectively eliminated from the blood . No data for edoxaban and apixaban or for the thrombin inhibitor dabigatran have been published so far. For dabigatran reversal, the humanised antibody fragment idarucizumab has been proven efficient. The drug is widely available and its cost is acceptable. Thus, idarucizumab clearly represents the therapy of choice in dabigatran-related bleeding. The evidence is less clear for the specific Xa inhibitor antagonist andexanet alfa. The drug costs are considerable, prothrombotic side effects have been reported and the clinical efficacy of andexanet alfa is not fully proven. A current meta-analysis revealed that prothrombin complex concentrate (PCC) showed comparable haemostatic efficacy to andexanet alfa, but PCC is currently not approved for Xa-inhibitor reversal . Thus, before suggesting CHP in bleeding TBI patients, we would highly recommend PCC as a Mouse monoclonal to CD64.CT101 reacts with high affinity receptor for IgG (FcyRI), a 75 kDa type 1 trasmembrane glycoprotein. CD64 is expressed on monocytes and macrophages but not on lymphocytes or resting granulocytes. CD64 play a role in phagocytosis, and dependent cellular cytotoxicity ( ADCC). It also participates in cytokine and superoxide release more rapid, widely available, and less invasive alternative for Xa-inhibitor reversal compared to CHP. We agree with Honore et al. that CHP might represent an interesting alternative to eliminate ticagrelor. For bleeding patients under NOACs, a variety of specific and unspecific reversal agents are available. Thus, before recommending an invasive procedure such as CHP 42-(2-Tetrazolyl)rapamycin in TBI patients, both safety and efficacy have to be confirmed in vivo. Acknowledgements We would like to thank Dr. Melissa Jackson for critical review of the manuscript. Abbreviations TBITraumatic brain injuryDDAVPDesmopressinNOACsNew oral anticoagulants Authors contributions PMH, SR and DDB designed the paper. All authors participated in drafting and reviewing. The authors read and approved the final version of the manuscript. Funding.