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The management of bleeding in patients receiving direct oral anticoagulants including the role of the new reversal agents
S40
Pathology (2017), 49(S1)
PATHOLOGY 2017 ABSTRACT SUPPLEMENT
Increased availability of genetic testing and better recognition of molecular lesions, empower the haematologist with enhanced diagnostic reproducibility and prognostic information. The CSF3R, SETBP1 and SF3B1 mutations which are frequently found in chronic neutrophilic leukaemia, atypical chronic myeloid leukaemia and mylodysplastic syndrome with ringed sideroblasts are elegant examples. Recognising the CSF3R or SETBP1 mutations and correlating with the bone marrow morphology allows a greater degree of certainty in these rare neoplasms. The SF3B1 mutation is found in cases of myelodysplastic syndromes with ringed sideroblasts and confers a good prognosis. Myelodysplastic syndromes are renamed to reflect the dysplasia (MDS) rather than the cytopenia. They retain a statement of unilineage or multineage dysplasia, the blast count category and whether ringed sideroblasts are present. Rationalisation of the classification includes moving mast cell diseases from the myeloproliferative category to stand alone, the removal of erythroleukaemia (erythroid/myeloid) altogether, and defining which cells are to be included in the bone marrow differential count. Germ-line neoplastic predisposition has also been incorporated into the revision. This fascinating and evolving addition to our understanding of the pathogenesis of several myeloid malignancies has the potential for creating moral and ethical challenges for haematologists, their patients and the patients’ families but also has important implications for therapeutic decisions. These examples and other specific changes are presented and incorporated into an overview of the classification to assist with the transition from the 2008 WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues to the 2016 revision.
Reference 1. Arber DA, Orazi A, Hasserjian R, et al. The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood 2016; 127: 2391 – 405.
THE MANAGEMENT OF BLEEDING IN PATIENTS RECEIVING DIRECT ORAL ANTICOAGULANTS INCLUDING THE ROLE OF THE NEW REVERSAL AGENTS Simon McRae Department of Haematology, SA Pathology, SA, Australia The management of major bleeding or urgent surgery in the setting of anticoagulation with the direct oral anticoagulants (DOACs) is a not uncommon clinical scenario. A specific reversal agent is now reversible for dabigatran, and is likely to be available for the Xa-inhibitors within the next 24 months. These agents are, or are likely to be, associated with significant cost, and reversing anticoagulation may be associated with thrombotic risk. An assessment of drug level in individual patients may often aid decision making regarding patient management, and where time allows laboratory assessment of residual anticoagulant effect should be made. Major hospital hospitals should therefore develop strategies to expedite laboratory assessment of the DOACs, with measurement of anti-Xa activity most useful for apixaban and rivaroxaban, and thrombin time and aPTT for dabigatran. This talk will discuss the current evidence for intervention in patients with bleeding while receiving a DOAC, and the role of the laboratory in this process.
Pathology (2017), 49(S1)
PATHOLOGY 2017 ABSTRACT SUPPLEMENT
Increased availability of genetic testing and better recognition of molecular lesions, empower the haematologist with enhanced diagnostic reproducibility and prognostic information. The CSF3R, SETBP1 and SF3B1 mutations which are frequently found in chronic neutrophilic leukaemia, atypical chronic myeloid leukaemia and mylodysplastic syndrome with ringed sideroblasts are elegant examples. Recognising the CSF3R or SETBP1 mutations and correlating with the bone marrow morphology allows a greater degree of certainty in these rare neoplasms. The SF3B1 mutation is found in cases of myelodysplastic syndromes with ringed sideroblasts and confers a good prognosis. Myelodysplastic syndromes are renamed to reflect the dysplasia (MDS) rather than the cytopenia. They retain a statement of unilineage or multineage dysplasia, the blast count category and whether ringed sideroblasts are present. Rationalisation of the classification includes moving mast cell diseases from the myeloproliferative category to stand alone, the removal of erythroleukaemia (erythroid/myeloid) altogether, and defining which cells are to be included in the bone marrow differential count. Germ-line neoplastic predisposition has also been incorporated into the revision. This fascinating and evolving addition to our understanding of the pathogenesis of several myeloid malignancies has the potential for creating moral and ethical challenges for haematologists, their patients and the patients’ families but also has important implications for therapeutic decisions. These examples and other specific changes are presented and incorporated into an overview of the classification to assist with the transition from the 2008 WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues to the 2016 revision.
Reference 1. Arber DA, Orazi A, Hasserjian R, et al. The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood 2016; 127: 2391 – 405.
THE MANAGEMENT OF BLEEDING IN PATIENTS RECEIVING DIRECT ORAL ANTICOAGULANTS INCLUDING THE ROLE OF THE NEW REVERSAL AGENTS Simon McRae Department of Haematology, SA Pathology, SA, Australia The management of major bleeding or urgent surgery in the setting of anticoagulation with the direct oral anticoagulants (DOACs) is a not uncommon clinical scenario. A specific reversal agent is now reversible for dabigatran, and is likely to be available for the Xa-inhibitors within the next 24 months. These agents are, or are likely to be, associated with significant cost, and reversing anticoagulation may be associated with thrombotic risk. An assessment of drug level in individual patients may often aid decision making regarding patient management, and where time allows laboratory assessment of residual anticoagulant effect should be made. Major hospital hospitals should therefore develop strategies to expedite laboratory assessment of the DOACs, with measurement of anti-Xa activity most useful for apixaban and rivaroxaban, and thrombin time and aPTT for dabigatran. This talk will discuss the current evidence for intervention in patients with bleeding while receiving a DOAC, and the role of the laboratory in this process.