American Society for Clinical Pathology
View all recommendations from this societySeptember 4, 2019
Do not perform a hypercoagulable workup in patients taking direct factor Xa or direct thrombin inhibitors.
Direct oral anticoagulants (DOACs) such as dabigatran etexilate, rivaroxaban, apixaban, edoxaban, and betrixaban often interfere with clot-based or chromogenic coagulation assays and may lead to inaccurate results or render the test uninterpretable. Affected tests include many commonly ordered tests on hypercoagulable workup panels: Lupus anticoagulant (LA) panels, activated protein C resistance, protein C and protein S activity, antithrombin activity, and specific factor activity levels. These tests should not be done in patients taking DOACS. If there is a compelling reason to perform these tests, great caution must be taken to avoid acting on a false result. For instance, specimens should be collected at the medication trough, and potential test interference should be considered prior to ordering. The potential for interference is dependent on test methodology, drug mechanism of action, and drug concentration. For patients suspected clinically to have antiphospholipid antibody syndrome, the lupus anticoagulant panel may be uninterpretable, but ELISA-based anticardiolipin and anti-beta2 GP1 antibody testing is unaffected. Genetic testing, such as PCR for factor V Leiden, is also unaffected.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
How The List Was Created
1-5: The American Society for Clinical Pathology (ASCP) list was developed under the leadership of the chair of ASCP’s Institute Advisory Committee and Past President of ASCP. Subject matter and test utilization experts across the fields of pathology and laboratory medicine were included in this process for their expertise and guidance. The review panel examined hundreds of options based on both the practice of pathology and evidence available through an extensive review of the literature. The laboratory tests targeted in our recommendations were selected because they are tests that are performed frequently; there is evidence that the test either offers no benefit or is harmful; use of the test is costly and it does not provide higher quality care; and, eliminating it or changing to another test is within the control of the clinician. The final list is not exhaustive (many other tests/procedures were also identified and were also worthy of consideration), but the recommendations, if instituted, would result in higher quality care, lower costs, and more effective use of our laboratory resources and personnel.
6–15: The American Society for Clinical Pathology (ASCP) list of recommendations was developed under the leadership of the ASCP Choosing Wisely Ad Hoc Committee. This committee is chaired by an ASCP Past President and comprises subject matter and test utilization experts across the fields of pathology and laboratory medicine. The committee considered an initial list of possible recommendations compiled as the result of a survey administered to Society members serving on ASCP’s many commissions, committees, and councils. The laboratory tests targeted in our recommendations were selected because they are tests that are performed frequently; there is evidence that the test either offers no benefit or is harmful; use of the test is costly and it does not provide higher quality care; and
eliminating it or changing to another test is within the control of the clinician. Implementation of these recommendations will result in higher quality care, lower costs, and a more effective use of our laboratory resources and personnel.
16-35 The American Society for Clinical Pathology (ASCP) list of recommendations was developed under the leadership of the ASCP Effective Test Utilization Steering Committee. This committee is chaired by an ASCP Past President and is comprised of subject matter and test utilization experts across the fields of pathology and laboratory medicine. The committee considered a list of possible recommendations compiled as the result of a survey administered to Society members serving on ASCP’s many commissions, committees and councils. In addition, an announcement was made to ASCP’s newly formed Advisory Board seeking suggestions for possible recommendations to promote member involvement. The laboratory tests targeted in our recommendations were selected because they are tests that are performed frequently; there is evidence that the test either offers no benefit or is harmful; use of the test is costly and it does not provide higher quality care; and eliminating it or changing to another test is within the control of the clinician. Implementation of these recommendations will result in higher quality care, lower costs and a more effective use of our laboratory resources and personnel.
ASCP’s disclosure and conflict of interest policy can be found at www.ascp.org.
Sources
Adcock DM, Gosselin R. Direct Oral Anticoagulants (DOACs) in the Laboratory: 2015 Review. 2015;136:7-12.
Lauren M. Murer, Samuel J. Pirruccello, Scott A. Koepsell; Rivaroxaban Therapy, False-Positive Lupus Anticoagulant Screening Results, and Confirmatory Assay Results, Laboratory Medicine, Volume 47, Issue 4, 1 November 2016, Pages 275–278, https://doi.org/10.1093/labmed/lmw029.
