1. Common Bleeding Disorders : Diagnosis and Treatment Michael Laposata, M.D., PhD Edward and Nancy Fody Professor of Pathology Vanderbilt University School of Medicine Pathologist in Chief, Vanderbilt University Hospital

2. Common Bleeding Disorders : Diagnosis and Treatment Michael Laposata, M.D., PhD I have no disclosures to make that are relevant to this presentation and will make no reference to any specific product or company with which I am connected.

3. Common Bleeding Disorders : Diagnosis and Treatment To learn the basic cellular and molecular events associated with blood coagulation. To understand the evaluation of a patient with a hemorrhagic disorder. To learn the pathogenesis of disseminated intravascular coagulation and bleeding associated with liver disease. To understand the indications and use of the anticoagulants warfarin and heparin.

4. Common Bleeding Disorders : Diagnosis and Treatment This patient has a platelet count of 250,000/mL and a normal PT and PTT. The platelet aggregation studies are abnormal. Which of the following is true? a)the patient has a qualitative platelet disorder but not a quantitative platelet disorder. b) the patient has a quantitative platelet disorder but not a qualitative platelet disorder. c) the patient has both a quantitative and a qualitative platelet disorder. d) the patient has no platelet disorder.

5. OUTLINE OF PRESENTATION 1. Clot Formation and Overview of the Diagnosis of Bleeding Disorders 2. Bleeding History 3. Bleeding Disorders and Severity of Thrombocytopenia 4. Bleeding Disorders and Decreased Platelet Function— Including von Willebrand’s Disease 5. Common Bleeding Disorders Associated with Prolongations of the PT, PTT or both & HIT

6. Clot Formation and Overview of the Diagnosis of Bleeding Disorders

7. Vessel Wall Injury CLOT FORMATION Platelet Adhesion Fibrin Formation Vessel Wall Contraction Platelet Aggregation - -- - - - -- - -

8. Platelets THE ELEMENTS OF HEMOSTASIS Coagulation Factors Fibrinogen Factor II Tissue Factor Factor V Factor VII Factor VIII Von Willebrand Factor Factor IX Factor X Factor XI Factor XII Factor XIII Blood Vessels

9. ThrombosisBleeding Balance The Appropriate Level of Hemostasis

10. Too Much Anticoagulation in a Thrombotic patient ThrombosisBleeding Balance 12

11. A Bleeding Patient with a High Risk for Thrombosis ThrombosisBleeding Balance

12. Bleeding History

14. FIRST POINT IN DIFFERENTIAL DIAGNOSIS: COAGULATION FACTORS VS. PLATELETS

15. Bleeding History PREOPERATIVE HEMOSTASIS EVALUATION Negative Preoperative evaluation dictated by surgical procedure Establish diagnosis of coagulopathy and if possible the successful measures for hemostasis Positive Platelets Coagulation Factors Number: platelet count Function: not the bleeding time PTPTT Treatment, if any, of abnormal lab values depends on cause of abnormality, degree of abnormality and severity of hemostatic challenge

16. Bleeding History OPERATIVE & POSTOPERATIVE HEMOSTASIS EVALUATION CoagulopathySurgical Bleed From Procedure? PlateletsCoagulation Factors Number: platelet count Function: not the bleeding time PTPTT

17. BLEEDING HISTORY Epistaxis: Infrequent, brief, self-limited episodes Easy bruising with trauma Prolonged bleeding after brushing teeth Dental extraction: prolonged bleeding* Hemoptysis Hematemesis Melena Obstetrical/Gynecological Bleeding (menorrhagia, post-partum Post-Operative Bleeding (prolonged* or delayed) Intracranial Hemorrhage Umbilical Hemorrhage Positive Family History 111222223344111222223344 For each of the following positive findings, add up the indicated number of points:

18. BLEEDING HISTORY Excessive bleeding following injury to mouth or loss of deciduous teeth Prolonged bleeding from minor injuries* Epistaxis: Frequent prolonged, or requiring treatment Hematuria Hemarthrosis in absence of major trauma Telanglectasia Petechiae Likelihood for a coagulopathy: > 10Highly suspicious 5 - 9Suspicious < 5Not suspicious 55558885555888 Each of the above should have no surgical or anatomic lesion to account for the bleeding. *prolonged bleeding = more than one hour

19. YES PREOPERATIVE COAGULATION TESTING Screening history for bleeding is negative & minor surgery Screening history for bleeding is negative & prior surgery without problems Screening history suspicious for bleeding or surgical procedure which may impair hemostasis or surgical procedure in which a small bleed is hazardous No screening tests but PT/PTT/Platelet count not unreasonable No screening tests but PT/PTT/Platelet count not unreasonable PT / PTT / Platelet count- bleeding time is not likely to be useful - von Willebrand testing and platelet aggregation studies reasonable YES NO

20. Bleeding Disorders and Severity of Thrombocytopenia

21. PLATELET NUMBER VS. BLEEDING RISK 400,000 Bleeding manifestation 300,000 Severe spontaneous bleeding Spontaneous bleeding Abnormal bleeding with trauma 200,000 100,000 150,000 40,000 10,000 Normal Range Adequate for Hemostasis Platelet count / µL Hemostasis & Thrombosis: A Conceptual Approach, 1979

22. QUANTITATIVE PLATELET DISORDERS Thrombocytopenia Very Common Thrombocytosis Not Common

23. THROMBOCYTOPENIA Decreased platelet production: Platelet transfusion increases the platelet count Increased platelet destruction: Platelet transfusions usually do not increase the platelet count and, if they do, it is for only short periods

24. CAUSES OF THROMBOCYTOPENIA Immune Immune thrombocytopenic purpura-acute & chronic Post-transfusion purpura Neonatal alloimmune thrombocytopenic purpura Drug-induced purpura Non-immune Disseminated intravascular coagulation Thrombotic thrombocytopenic purpura Selected drugs

25. Bleeding Disorders And Decreased Platelet Function- Including Information on von Willebrand’s Disease

27. DIAGNOSIS OF COAGULOPATHIES INVOLVING COAGULATION FACTORS Screening Tests: Further Evaluation: Result: PT & PTT Mixing Studies Factor Assays Inhibitor Assays > 90% success rate in determining etiology of abnormal PT / PTT

28. DIAGNOSIS OF COAGULOPATHIES INVOLVING PLATELET FUNCTION Screening Tests & Further Evaluation: Several tests available – results may not agree Complex Assays for Wide Variety of Molecules Result: When a bleeding patient has a normal PT, PTT and platelet count, it is usually very difficult to determine if there is a platelet function defect which may explain the bleeding.

29. DIAGNOSTIC OVERVIEW PT / PTT Normal - Coagulation Factors Adequate Platelet Count Normal - Platelet Number Adequate If Yes, Presume Platelet Function Defect, but Which Qualitative Platelet Disorder and Will Platelet Transfusion Promote Hemostasis? BLEEDING?

30. PLATELET AGGREGATION STUDIES: THE AGONISTS AGONIST Collagen Arachidonate ADP Epinephrine Ristocetin RELATIVE POTENCY Strong Moderate - Weak Weak Strong - Weak

32. VerifyNow™ Aspirin Rapid, easy, and accurate RAPID –Result available in 5 minutes EASY –Whole blood - no sample preparation –Automatic sampling from closed tube –Factory calibrated reagents –Internal quality controls ACCURATE –A quantitative reference point measured in ARUs that correlate to the gold standard of optical aggregometry COST-EFFECTIVE –Reimbursement/ CPT code –CLIA-waived Insert assay device Add blood sample Result in one to five minutes

33. VERIFYNOW TM ASPIRIN MIMICS OPTICAL AGGREGOMETRY From VerifyNow

34. DIAGNOSIS OF COAGULOPATHIES INVOLVING PLATELET FUNCTION Causes of Acquired Disorders Drugs (Hundreds) Uremia Paraproteins Many Others Causes of Congenital Disorders IIb - IIIa Deficiency Ib - IX - V Deficiency Alpha, Delta or Alpha/Delta Granule Deficiency Von Willebrand Factor Abnormality Cyclooxygenase Deficiency Thromboxane Synthetase Deficiency Thromboxane Receptor Deficiency If platelet aggregation studies are abnormal, what tests should be performed subsequently to identify the specific platelet function defect?

35. von Willebrand’s Disease – Diagnosis and Treatment

36. VON WILLEBRANDS DISEASE: PATTERN OF BLEEDING 95% of Bleeding Episodes of von Willebrand’s Disease Patients are Mild to Moderate Common Bleeding Episodes: Mucosal Bleeding Bleeding After Surgery and Dental Extractions

37. THE TWO DIFFERENT ACTIVITIES OF THE FACTOR VIII-VON WILLEBRAND FACTOR COMPLEX FibrinogenFibrin XII XI IXVII VIIIvW VIII Blood Vessel Wall vW PLT vW PLT XXa III IIIIa V

38. TYPE 1 VON WILLEBRAND’S DISEASE Quantitative disorder with normal multimer distribution - von Willebrand factor and ristocetin cofactor decreased approximately equally Factor VIII may be normal or low VIII

39. DDAVP can completely correct entire defect if it is mild, by stimulating vW Factor release from endothelium TYPE 1 VON WILLEBRAND’S DISEASE

40. Decrease in high molecular weight multimers in plasma and sometimes in platelets Synthesis of large multimers defective or increased proteolysis of large multimers Ristocetin cofactor and von Willebrand factor antigen both very low TYPE 2A VON WILLEBRAND’S DISEASE

41. Decrease in high molecular weight multimers in plasma only High molecular weight multimers of vW factor removed from plasma by binding to normal platelets Plasma ristocetin cofactor and von Willebrand factor antigen both very low Platelet Membrane Plasma TYPE 2B VON WILLEBRAND’S DISEASE

42. TYPE 3 Quantitative disorder with nearly undetectable levels of von Willebrand antigen and ristocetin cofactor Either markedly reduced synthesis of normal von Willebrand factor or synthesis of a highly dysfunctional von Willebrand factor

43. Multimer Analysis for Types and Subtypes of von Willebrand’s Disease

44. INFLUENCE OF ABO BLOOD GROUP ON vW FACTOR ANTIGEN VALUES IN VOLUNTEER BLOOD DONORS ABO Type O A B AB von Willebrand Factor Mean Value 74.8 105.9 116.9 123.3 n 456 340 196 109 Blood 69, 1691-1695, 1987

45. TEST FOR DDAVP RESPONSE Normal response of a normal subject Lack of response N. Engl. J. Med., 318-881-887, 1988 vWF 300 275 250 225 200 175 150 125 100 75 -15 0 15 30 45 60 75 90 105 120 135 150 165 Time (Minutes) vWF 300 275 250 225 200 175 150 125 100 75 -15 0 15 30 45 60 75 90 105 120 135 150 165 Time (Minutes) DDAVP Infusion

46. Common Bleeding Disorders Associated with Prolongations of the PT, PTT or both & Heparin-Induced Thrombocytopenia

47. MOST CASES WITH COAGULATION FACTOR DEFICIENCES ARE MULTIPLE AND ACQUIRED In liver disease, all the factors except VIII are low In DIC, there is consumption of factors V, VIII fibrinogen and others With Warfarin and low vitamin K - There are decreased amounts of factors II, VII, IX, and X In proteinuria, there may be decreases in both factors XI and XII

48. DISSEMINATED INTRAVASCULAR COAGULATION (DIC) 1) DIC is always a response to an underlying process 2) It results in a generalized activation of hemostatic mechanism 3) The mortality in DIC is related to the underlying disease

49. DISSEMINATED INTRAVASCULAR COAGULATION (DIC) Infection Complications of Pregnancy Malignancy Massive Tissue Trauma Fibrin Formation Thrombin Platelet Activation Fibrin Degradation Products

50. CONDITIONS ASSOCIATED WITH THE DEVELOPMENT OF DIC Severe infections Complications of pregnancy - Amniotic fluid embolism - Premature separation of the placenta - Septic abortion - Retained dead fetus - Retained fetal products after delivery Malignancies Massive tissue trauma Hemorrhagic shock Severe liver disease Burns

51. Platelets Fibrinogen FDP or D-Dimer PT PRACTICAL LABORATORY EVALUATION FOR DIC Changes in DIC Low or decreasing Increased

52. DIAGNOSTIC AND THERAPEUTIC APPROACH TO DIC Bleeding controlled? DIC risk factor present Watch for bleeding Yes No Laboratory tests results consistent with DIC? DIC is present Is the patient bleeding? Plasma and platelets, possibly cryoprecipitate for hemostasis, and packed red blood cells

53. Factor as unmodified protein Warfarin Interrupts the Action of Vitamin K - Reducing the Amount of Functional Factors II, VII, IX, and X Factor with gamma carboxy- glutamic acids Warfarin Vitamin K epoxide reductase activity Vitamin K Epoxide CH 2 COOH CH 2 HC - COOH COOH

54. ALGORITHM FOR WARFARIN USE Maintain As Necessary Overdose? Desire to regain the anticoagulated state as soon as possible? Significant bleeding? Stop warfarin & administer vitamin K Discontinue warfarin - give plasma and Vit K to stop bleeding Decrease dose from before Yes No Maintain INR at 2.0 - 3.0 or 2.5-3.5 Discontinue warfarin & allow INR to decline

55. 1) Thrombosis/embolism - primary or recurrent 2) Anticipated thrombosis from atrial fibrillation 3) Anticipated thrombosis from presence of prosthetic heart valves COMMON INDICATIONS FOR WARFARIN THERAPY Rapid Onset Anticoagulant ClotWarfarin

56. In most circumstances, do not administer with anti-platelet drugs (aspirin) to avoid bleeding complications With appropriate reagents, adequate anti- coagulation when PTT is > 2.0 X mean of normal PTT range; cannot give orally or instramuscularly- given IV or subcutaneously Half life of unfractionated heparin usually 60-90 minutes-effect quickly reversible with discontinuation of heparin OVERVIEW OF HEPARIN THERAPY WITH STANDARD UNFRACTIONATED HEPARIN

57. ALGORITHM FOR HEPARIN USE No Monitoring Maintain as Necessary Full-dose unfractionated heparin PTT to > 2.0 X mean of normal range Overdose? Prophylaxis Low molecular weight heparin prophylaxis or therapy in non-obese adults with normal renal function? Significant bleeding? Stop heparin- Neutralize with protamine sulfate More protamine sulfate Persistent bleeding? Discontinue heparin - & watch carefully for at least 2 hours Bleeding? Decrease heparin dose Yes No

58. NAME I (Fibrinogen) II (Prothrombin) III (Tissue Factor) V VII VIII Von Willebrand Factor IX X XI XII XIII COAGULATION FACTORS: SITE OF SYNTHESIS Liver/Megakaryocyte Liver, Vitamin K Dependent Multiple Body Tissues Liver/Megakaryocyte Liver, Vitamin K Dependent Liver & Other Site(s) Endothelial Cells/ Megakaryocytes Liver, Vitamin K Dependent Liver Liver/Megakaryocyte

59. Congenital factor Deficiencies – Some are rare, others are uncommon and some are high incidence

60. FACTOR I II V VII VIII IX X XI XII XIII INCIDENCE OF CONGENITAL DEFICIENCY RARE NOT UNCOMMON RARE COMMON RARE

61. An Example of Not Uncommon Coagulation Factor Deficiencies with Serious Bleeding – Hemophilia A and Hemophilia B

62. HEMOPHILIA A HEMOPHILIA A & B DEFICIENCY OF FACTOR VIII IN THE COAGULATION CASCADE HEMOPHILIA B DEFICIENCY OF FACTOR IX IN THE COAGULATION CASCADE

63. DISEASE PATTERN: HEMOPHILIA A & HEMOPHILIA B Severe Moderate Mild Inhibitors Present < 1% Activity 1-5 % Activity 5-50 % Activity Patients (%) 0102030405060

64. HEMOPHILIA A & HEMOPHILIA B Genetics of Inheritance: X - Linked Transmission Mother Carrier Father Normal Mother Normal Father Hemophiliac OR X X YX X Y X X Y CarrierNormal HemophiliacCarrier Normal

65. The Use of Recombinant Factor VIIa Patients with hemophilia A or hemophilia B complicated by inhibitors: Not controversial Factor VII Deficiency: Not controversial Intracerebral Hemorrhage: Controversial Uncontrolled hemorrhage following surgery or trauma: Controversial – limited number of controlled trials but large number of anecdotal reports of hemostatic advantage over conventional therapy

66. Bleeding History OPERATIVE & POSTOPERATIVE HEMOSTASIS EVALUATION CoagulopathySurgical Bleed From Procedure? PlateletsCoagulation Factors Number: platelet count Function: not the bleeding time PTPTT

67. SUMMARY OF PRESENTATION 1. Clot Formation and Overview of the Diagnosis of Bleeding Disorders 2. Bleeding History 3. Bleeding Disorders and Severity of Thrombocytopenia 4. Bleeding Disorders and Decreased Platelet Function— Including von Willebrand’s Disease 5. Common Bleeding Disorders Associated with Prolongations of the PT, PTT or both & HIT