CytoSorbents Corporation (CTSO)

[TwoNE1]

Thanks. To make your message complete, here is the Authors’ response:
Herbert Schöchl, 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 [5].

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 [2]. Albumin represents an alternative approach to bind ticagrelor. An experimental study using high-dose albumin spiking of blood samples containing ticagrelor resulted in a significant improvement of platelet function [6]. This might be considered a 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 [4]. 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 [7]. Thus, before suggesting CHP in bleeding TBI patients, we would highly recommend PCC as a 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 in TBI patients, both safety and efficacy have to be confirmed in vivo.

source: https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-02922-6