Italian 
English Due pazienti fragili in Pronto Soccorso: il ruolo del laboratorio nel monitoraggio della terapia con anticoagulanti orali ad azione diretta
Two frail patients in the Emergency Room: the laboratory role in the monitoring of the direct anticoagulants therapy
AUTORI
1Dipartimento di Medicina di Laboratorio, UOC Laboratorio Analisi Chimico Cliniche, Azienda Ospedaliero-Universitaria Pisana (AOUP), Pisa
2Dipartimento di Medicina di Laboratorio, UOC Laboratorio Analisi Chimico Cliniche, Centro Antitrombosi FCSA (Federazione Centri per la diagnosi della trombosi e la Sorveglianza delle terapie Antitrombotiche) n. 281 (AOUP), Pisa
3Dipartimento di Medicina di Laboratorio, SD Patologia Clinica Azienda Ospedaliero-Universitaria Pisana (AOUP), Pisa
ABSTRACT
Two frail patients in the Emergency Room: the laboratory role in the monitoring of the direct anticoagulants therapy
This case report is about two frail women admitted to the Emergency Room. The first patient, with a history of alcohol dependence, accessed to First Aid because of an accidental fall; she presented anemia, and elevation of the coagulation tests (prothrombin time 3.02; activated partial thromboplastin time 2.45). After the clinicians’ prescription for the measurements of coagulation factors, the FII was found significantly reduced (6%). Suspecting previous assumption of dabigatran (not declared at the admission), the laboratory decided to measure the plasma concentration of dabigatran, which resulted rather elevated (658 ng/mL). The second patient, aged 94, accessed to the first aid for anuria. Laboratory tests revealed severe anemia, kidney impairment and elevated coagulation tests. The patient was on dabitagran and verapamil. The dabitagran plasma concentrations were particularly elevated (1 224 mg/L. The dabitagran was discontinued in both patients and its plasma concentrations decreased rapidly; the coagulation tests returned to normal. Stroke prevention in elderly people with atrial fibrillation is of great importance, as stroke risk rises greatly with age. The elderly and frail patients have more favourable outcomes when on direct oral anticoagulant (DOACs). The use of these drugs in daily clinical practice does not require monitoring of coagulation. However, the measurement of DOACs is advisable in certain situations, as demonstrated in these two case reports, since elevated drug concentrations. pose the patients at an increased bleeding risk. Anticoagulant activity can be measured easily measured in laboratory practice, using specific coagulation assays developed for the quantification of DOACs plasma levels