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Volume 4 Issue 1 August 2013

Stago Newsle er

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INSIDE THIS ISSUE:

STA Liatest D-Dimer Plus 2

STA Liquid Fib 3

STA Rivaroxaban Cals and QC 4

iHemOStasis 5

2013 Stago Catalogue 6

STA ImmunoDef VIII and IX 7-8

Dates to remember 9

Apixaban Cals and QC 9

STA Liatest® D-Dimer Plus D-Dimer is a routine test for most laboratories across the world. As a marker of fibrinolysis, it can be raised in various situations and play an important role in a diagnosis scheme, particularly when associated with other parameters and/or included in a clinical score (eg Wells score) determination. However, as of today, the main clinical uses of D-Dimer remain Deep Venous Thrombosis (DVT)/Pulmonary Embolism (PE) Exclusion and Disseminated Intravascular Coagulation (DIC) monitoring and diagnosis due to the prevalence and incidence of these diseases and well documented use of D-Dimer in these two diagnostic work-ups.

Criteria for selecting a good D-Dimer assay are influenced by international recommendations emanating from laboratory and clinical scientific societies, health authorities or state-of-the-art (eg. publications).

When selecting a D-Dimer assay, laboratories would therefore consider several aspects:

• Claimed and validated clinical performances for the main D-Dimer clinical indication (exclusion of DVT/PE)

• Analytical performances for reliable results

• Operational performances (practicability) for a use adapted to laboratories’ constraints and expectations.

STA Liatest® D-Di is widely used by laboratories across the world since its launch in 1998 and has been recognised for its excellent operational and analytical performances together with its well published and recognised clinical performances in VTE exclusion as well as in other indications.

Interferences with human antibodies present in patient samples are a commonly known issue that can be encountered when performing

immunoassays for diagnostic testing. The prevalence of such interfering agents is difficult to assess as it may vary considerably. Heterophilic antibodies, in particular Human Anti-Mouse Antibodies (HAMA) and Rheumatoid Factors (RF) are known to interfere with D-Dimer assays by over-elevating the result.

As this interference can lead to false positives and misdiagnosis – particularly in VTE exclusion – this issue has been reported in literature and customers have requested D-Dimer assay providers to identify and address this limitation when it exists.

As part of Stago’s continuous improvement commitment, The STA Liatest® D-Di PLUS has been designed as an evolution of the STA Liatest® D-Di specifically to address this need. With the addition of a blocking agent in the reaction buffer, STA Liatest® D-Di PLUS eliminates interferences associated with RF up to 1000 IU/ml and minimises interferences from heterophilic antibodies and HAMA, whilst keeping all other existing performances of STA Liatest® D-Di.

The same packaging, the same test setups, the same antibodies and latex, fully automated on Stago analysers, same 15 day on-board stability, same controls (00526 STA Liatest® Control N+P, and same rapid turn around time for results (< 7 minutes). In 2013, 00662 STA Liatest® D-Di PLUS will start to replace 00515 STA Liatest® D-Di. The identical and excellent performances of both assays will make for an easy transition for our customers.

If you would like to know more please contact us at info@stago.com

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may lead to bleeding and/or thrombosis . Traditionally, fibrinogen assays have been required in the investigation of haemorrhagic states .

The Clauss assay is considered as the reference method . A high concentration of thrombin is added to diluted test plasma and the clotting time is measured (Clauss, 1957). The test result is compared with a calibration curve prepared by clotting a series of dilutions of a reference plasma sample of known concentration, and a result in g/l is obtained.

Stago are pleased to announce a new reagent, the STA®-Liquid Fib , which is intended to replace both STA®-Fibrinogen 5 and STA®-Fib 2.

It features the following:

- a liquid format for an improved ease of use

- an extended stability to improve the

STA® Liquid Fib

Fibrinogen functions in primary haemostasis in support of platelet aggregation and in secondary haemostasis in the formation of an insoluble fibrin clot . It is the final clotting factor activated in the coagulation cascade.

Mainly synthesised in the liver , human fibrinogen is the product of three closely linked genes , each specifying the primary structure of the α, β and γ polypeptide chains, located on chromosome 4.

Inherited and acquired disorders can alter the quantity (afibrinogenemia and hypofibrinogenemia) and function (dysfibrinogenemia) of plasma fibrinogen.

Hypofibrinogenemia is generally asymptomatic , but afibrinogenemia and dysfibrinogenemia

laboratory efficacy

• The STA®-Liquid Fib is a high quality reagent that contributes to Stago's Premium Routine Line .

• Clauss method - Gold standard

• Working range 0.4 to 12 g/l - Covers all clinical situations, no need to re-test low QC with lower dilution (rare cases)

• Liquid format - Ready to use, no reconstitution steps

• Pre-calibrated, Time saving: no calibration required (Calibration is possible) and fully automated

• Barcoded reagents - Ensures traceability, Ease of use, confidence and security of results

• Extended stability - 10 days on board; 2 months at 2~8°C

• STAT compliance

- reagent available 24/7

- results available in a few minutes

• Optimized packaging/stability to enable no waste of reagent

Diagnostica Stago ANZ will be rolling this reagent out to our customers over the next 12 months.

If you would like to know more please contact us at info@stago.com

00673 STA®-Liquid Fib

available soon

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STA® Rivaroxaban QC and Calibrators

Rivaroxaban is a new oral

an�coagulant, direct factor Xa

Inhibitor, developed by Bayer

HealthCare and sold under the

trade name Xarelto®.

It is approved in three indica�ons in

Europe:

· preven�on of stroke and

systemic embolism in adult pa�ents

with non-valvular atrial fibrilla�on

(AF) with one or more risk factors

· treatment of deep vein

thrombosis (DVT) and preven�on of

recurrent DVT and pulmonary

embolism (PE) following an acute

DVT in adults

· preven�on of VTE in adult

pa�ents undergoing elec�ve hip or

knee replacement surgery.

In the US, Xarelto is approved for

stroke preven�on in AF pa�ents and

preven�on of VTE in hip or knee

surgery.

In April 2012, the TGA approved

Xarelto® for the preven�on of stroke

and systemic embolism in pa�ents

with non-valvular atrial fibrilla�on

(NVAF) and at least one addi�onal

risk factor for stroke, and treatment

of deep vein thrombosis (DVT) and

preven�on of recurrent DVT and

pulmonary embolism in Australia.

In total, Rivaroxaban is approved in

more than 110 countries worldwide.

This makes Rivaroxaban a future

major player in the world of

an�coagulants.

Rivaroxaban is contraindicated in

renal impairment (crea�nine

clearance <15mL/min), moderate

and severe hepa�c impairment with

elevated INR, or with azole

an�fungals or HIV-protease inhibi-

tors. These increase blood levels of

Rivaroxaban and therefore bleeding

risk.

The Stago STA®-Rivaroxaban

Calibrator & Control, is a new

solu�on for the determina�on of

Rivaroxaban concentra�on required

to support the examina�on of

pa�ents in different clinical

situa�ons.

This solu�on uses the an�-Xa

method (00311 STA®-Liquid

An�-Xa), is insensi�ve to analy�cal

and biological variables, and has a

wide working range.

00704 STA® Rivaroxaban Calibrator

(3 vials x 4 levels x 1ml)

00706 STA® Rivaroxaban Control

(3 vials x 2 levels x 1ml)

Email info@stago.com

fax +61 3 9855 8999 or

phone 1800 4 78246 Australia

0508 4 78246 New Zealand

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Stago are pleased to announce the release of our iPad application iHemOStasis . This application, available free of charge from the Apple App Store worldwide, is the first high-level educational tool exclusively dedicated to the in-depth study of Hemostasis and Thrombosis.

It includes:

5 animations related to Hemostasis:

♦ Primary Hemostasis,

♦ Coagulation Cascade,

♦ Fibrin Formation and Fibrinolysis,

♦ Inhibitors of coagulation,

♦ Anticoagulants

Special Focus

5 information "leaflets" on specific topics:

♦ Anticoagulants,

♦ Thrombin generation,

♦ Flow cytometry,

♦ Reference values: Hemostasis and Pediatrics

♦ Reference values: Hemostasis and Pregnancy

A Quick Guide to Hemostasis:

♦ Best practices,

♦ Reference values,

♦ Definitions and Glossary

Clinical Cases to test your knowledge with some real-life cases.

The iHemOStasis App is available now for download to iPad from the Apple App Store or iTunes (https://itunes.apple.com/app/id472966966) or scan the QR code above with your iPad.

iHemOStasis App

Scan this QR Code with your iPad

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2013 Stago Catalogue The Stago 2013 Haemostasis Catalogue is available in softcopy or hardcopy.

Please drop us a line if you would like one and specify the desired format: info@stago.com

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STA® ImmunoDef VIII and IX

Factor VIII is a plasma protein produced in

the liver and by the re�culoendothelial

system. Factor VIII acts as a cofactor in

the factor Xa-genera�ng enzyme complex

of the intrinsic coagula�on pathway. In

plasma, the factor VIII circulates in a

complexed form with the von Willebrand

factor, F. VIII/VWF. In this complex, the

factor VIII is a ached to the von

Willebrand factor by a noncovalent

linkage. The factor VIII can be ac�vated by

thrombin and factor Xa; it increases the

ac�va�on of factor X by the factor IXa in

the presence of phospholipids and

calcium.

A normal plasma ac�vity in the adult

popula�on is usually between 60 and 150

% (0.6 - 1.5 IU/mL) (1). Reference values

may differ according to the pa�ent's age,

sex as well as within ethnic groups (2).

Ranges can be established in each

laboratory according to their pa�ent

demographics and results should be

interpreted as such. It is most important

to evaluate coagula�on results based on

the popula�on tested.

Haemophilia A (factor VIII deficiency) is

the most common recessively inherited

X-linked bleeding disorder. Almost

exclusively males are affected (1 in every

10 000 births). Es�ma�ons based on the

World Federa�on of Haemophilia's (WFH)

annual global surveys indicate that the

number of people with haemophilia in the

world is approximately 400 000. (h p://

www.wO.org/en)

It is characterized by mild, moderate or

severe bleeding episodes. The severity of

haemophilia is based on factor VIII:C level:

- < 1 % (< 0.01 IU/ml): severe

haemophilia,

- 1-5 % (0.01 - 0.05 IU/ml): moderate

haemophilia,

- 5-40 % (> 0.05 - < 0.40 IU/ml): mild

haemophilia.

Treatment consists of subs�tu�on with

plasma derived or recombinant Factor VIII

(rFVIII).

Factor VIII inhibitor is the most serious

complica�on of replacement therapy with

factor VIII in children with severe

haemophilia. In that case, the factor VIII

level is decreased. It remains unclear why

it concerns only propor�on of pa�ents

with haemophilia A. Several factors are

reported: gene�c, environmental,

immunologic, treatment type.

Inhibitors are a serious medical problem

that can occur when a person with

haemophilia has an immune response to

treatment with cloQng factor

concentrates. The immune system

defends the body from harmful bacteria

and viruses. Some�mes in the case of an

inhibitor, a person’s immune system

reacts to proteins in factor concentrates

as if they were harmful foreign substances

because the body has never seen them

before. When this happens, inhibitors

(also called an�bodies) form in the blood

to fight against the foreign factor

proteins. This stops the factor

concentrates from being able to correct

the bleeding problem.

Factor IX is a vitamin K-dependent serine

protease produced in the liver. It

circulates in the plasma in its inac�ve

form. Factor IX can be ac�vated in two

different ways:

– factor XIa, in the presence of Ca++,

ac�vates factor IX to factor IXa

– �ssue factor: factor VIIa complex

ac�vates either factor X or factor IX.

Factor IXa forms an enzyma�c complex

with phospholipids, Ca++ and factor VIIIa;

this complex then ac�vates factor X to

factor Xa. Factor IX has usually a normal

plasma ac�vity of 60 - 150% (0.6 - 1.5 IU/

mL).

Haemophilia B (factor IX deficiency) is the

second most common recessively

inherited X-linked bleeding disorder.

Almost exclusively males are affected (1 in

every 30 000 births).

The severity of haemophilia is based on

factor IX:C level:

- < 1 % (< 0.01 IU/ml): severe

haemophilia,

- 1-5 % (0.01 - 0.05 IU/ml): moderate

haemophilia,

- 5-40 % (> 0.05 - < 0.40 IU/ml): mild

haemophilia.

Treatment consists in subs�tu�on with

plasma derived or recombinant factor IX.

Factor IX inhibitor is the most serious

complica�on and in that case, the factor

IX level is decreased.

From a clinical point of view an accurate

diagnosis for Factor VIII / IX deficiency is

essen�al to determine the haemophilia

classifica�on and assess the clinical

severity. Accurate diagnosis of

haemophilia is necessary to allow

appropriate pa�ent management.

Treatment

Prophylac�c factor replacement therapy

is a prerequisite for pa�ent-tailored

treatment strategy. Prophylaxis is the

treatment by intravenous injec�on of

factor concentrate in order to prevent

an�cipated bleeding.

In their Quality Assurance of the

manufacturing process, manufacturers

check the compliance with specifica�ons

of the factors concentrates they

produce.

Tes�ng

a. FIRST LINE COAGULATION TESTING

An APTT prolonga�on occurs for factors

deficiencies in pa�ents but it is not

sufficient for haemophilia diagnosis.

APTT Mixing study could then be

performed:

APTT measurement of mix of pa�ent

plasma + Normal plasma. In the case of

mixing study correc�on, second line co-

agula�on tes�ng should be performed.

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STA® ImmunoDef VIII and IX cont’d

b. SECOND LINE COAGULATION TESTING

A defini�ve diagnosis depends on the

factor assay to demonstrate a deficiency

of Factor VIII or IX.

- One stage assay is preferred by most

laboratories because of its simplicity and

automa�on. CloQng assay is the most

widespread. The Factor VIII / IX assay is

based on a comparison of the ability of

dilu�ons of standard and test plasmas to

correct the APTT of a plasma known to be

totally deficient in FVIII / IX but containing

all other factors required for normal

cloQng.

- For Factor VIII, two main alterna�ves to

the one stage assay exist: Two-stage APTT

based assay and two-stage chromogenic

based assay.

Both are based around an ini�al step to

produce factor Xa in a quan�ty

propor�onal to the amount of factor VIII

present and a second step to assay the

amount of factor Xa and so, deduce the

amount of factor VIII present.

In the chromogenic based assay, the

amount of FXa is measured by its ac�on

on a highly specific chromogenic sub-

strate. Since the colour intensity

produced is directly propor�onal to the

amount of FXa, which in turn is directly

propor�onal to the amount of FVIII, the

FVIII levels may be calculated from the

absorbance of the sample at a specific

wavelength (the op�mal absorbance

wavelength for the chromophore

produced by FXa cleavage of the

chromogen, e.g. 405nm for the commonly

used S-2765 chromogen).

Clinical plasma samples are assayed

mostly by one-stage assays, but

manufacturers of concentrates use the

chromogenic method, which is the

reference method of the European

Pharmacopoeia and the Interna�onal So-

ciety on Thrombosis and Haemostasis

(ISTH). But the chromogenic method is

not easily fully automated and can be very

expensive.

From the lab point of view, what are the

expecta�ons for factor assay

measurements?

► High standard performances

� To guarantee quality results &

pa�ent safety and especially at very low

levels for diagnosis and monitoring

treatment of pa�ents with haemophilia.

► Time effec�ve & easy to use product

for an op�mal cost management

� Customers would like to op�mise the

reagents used depending on their

laboratory ac�vity.

► Standardized results between labor-

atories for pa�ent follow up

� To have a consistent correla�on with

overall system.

► Compliance with Interna�onal

guidelines

The new STA-ImmunoDef VIII and IX

reagents have iden�cal principles to the

previous STA- Deficient VIII and IX

reagents.

The factor VIII and IX tests are

chronometric method based on one stage

cloQng �me method. Immuno-depleted

plasma, with all factors in excess except

factor VIII or IX, is added to pa�ent

plasma. The coagula�on is ac�vated by

the addi�on of the APTT reagent and cal-

cium.

Composi�on

► Packaging of STA – ImmunoDef VIII

(Cat. Nr. 00728) & IX (Cat. Nr. 00734)

� 6 vials x 1 mL

� Freeze-dried reagent

� Barcoded

� Dead volume: 0.5mL (use of

microcups or pooled vials is strongly

recommended to reduce the dead

volume)

� Theore�cal tests: 6x20 tests, ie 120

tests (iden�cal to STA – Deficient VIII &

IX).

► Shelf life: 24 months aXer

manufacturing

Key features

► Enhanced on board stability

The reagent is stable 8 hours on board.

Twice the stability of the current STA-

Deficient (4h).

► Extended Working range with one

unique calibra�on curve

STA® - ImmunoDef VIII: 0.7 to 400%

STA® - ImmunoDef IX: 0.7 to 300%.

There is no requirement for a low

calibra�on curve anymore.

► Stability of calibra�on

The frequency of the calibra�on is

reduced so it is no longer recommended

to perform calibra�on for each run. New

calibra�on is recommended only when

QC results are out of the range, typically

with change of lot number.

► Robustness of calibra�on curve

No addi�onal calibra�on and rerun of

QCs is necessary to obtain a valid

calibra�on.

► Addi�on of vWF factor in STA®-

ImmunoDef VIII. This follows the

Interna�onal guidelines for Besthesda &

Nijmegen test.

► A residual ac�vity < 1 %

If you would like to know more please contact us at info@stago.com

00728 STA® ImmunoDef VIII

00734 STA® ImmunoDef IX

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Dates to Remember

September 2 - 4, 2013

AIMS National Scientific Meeting 2013

Grand Hyatt Hotel Melbourne, Australia http://www.aims.org.au ____________________________________________________________

October 19 - 23, 2013

ASTH and HAA 2013 (ASTH Workshop October 19, 2013—Gold Coast Conferen ce & Exhibition Centre) Joint Annual Scientific Meeting of the HAA (HSANZ, ANZSBT and ASTH, 2013) Gold Coast Conference & Exhibition Centre Gold Coast, Australia http://www.fcconventions.com.au/HAA2013

____________________________________________________________

Diagnostica Stago Pty. Ltd.

651 Doncaster Road

Doncaster, VIC, 3108

Australia

Phone (AUS): 1800 4 STAGO

Phone (NZ): 0508 4 STAGO

Fax: +61 3 9855 8999

info@stago.com

www.stago.com.au

AUSTRALIA - NEW ZEALAND

At the Heart of Haemostasis

New science and the transfer of knowledge leads to new standards of care, better patient outcomes and improved quality of life for the patients we serve.

Diagnostica Stago, has long been committed to providing educational support to haemostasis testing laboratories. Our customers participate by providing feedback and program requests on specific topics that may aid them in the use of our products or provide knowledge to better serve as their institution’s haemostasis resource.

Australian and New Zealand participants can achieve APACE and CPD continuing education credits and certificates by registering and completing the activities on this site.

Please visit:

http://www.stago-edvantage.com/

Educational Website

24 hours per day 7 days per week

Welcome to Stago-EdVantage.com

Stago APIXABAN Calibrators and Controls

Coming Soon in 2013

Congratulations to James Barker from Austin Hospital

winner of the Stago Prize at RMIT University-May 2013