To monitor low molecular weight heparin (LWMH) therapy and sometimes to monitor unfractionated heparin (UFH) therapy
When you are being treated with LMWH or UFH and your doctor wants to monitor the amount of heparin in your blood
A blood sample taken from a vein in your arm
No test preparation is needed, although the timing of the test is important
This test measures the effect of low molecular weight heparin (LMWH) or unfractionated heparin (UFH) in the blood by measuring anti-Xa activity. Heparin is an anticoagulant, a drug that inhibits blood clotting. Heparin molecules vary in size and activity. UFH includes a broad range of sizes, while LMWH consists of a narrower range of smaller heparin molecules. There are several types of LMWH available and each one is slightly different. UFH is usually given intravenously (I.V.) and LMWH is usually given by a subcutaneous injection to people who have inappropriate blood clots (thrombi) and/or are at an increased risk of developing them.
Blood clotting is a normal response to blood vessel or tissue injury. It is a process that involves a sequential activation of proteins that regulate blood clot development. A variety of acute and chronic risk factors, including surgery, pregnancy and some oral contraceptives, serious illnesses and immobility are associated with inappropriate blood clot (thrombus) formation in veins – especially in the legs. These clots can obstruct blood flow and cause pain and swelling in the affected area. Pieces of the blood clot can break off and travel to the lungs - causing pulmonary embolism.. Heparin can also inhibit blood clot formation in diseased arteries, which sometimes cause heart attacks or strokes.
Heparin, through its action on a protein called Antithrombin, interferes with the clotting process by accelerating the inhibition of coagulation factors, particularly factors Xa and IIa (thrombin). UFH, which affects both Xa and IIa, is more variable in its inhibitory activity, and must be closely monitored using a variety of tests including the APTT, ACT or less commonly by anti-Xa. Complications may include bleeding, and sometimes a serious complication called “HIT” (Heparin Induced Thrombocytopenia) causing a low platelet count and thrombosis at the same time. UFH is usually given in a hospital setting. High doses of UFH are given during surgery requiring cardiopulmonary bypass.
LMWH has more anti-Xa action than anti-IIa activity and the response to it is more predictable. It may be given in either an outpatient or hospital setting. Routine monitoring of LMWH is seldom required but when it is monitored, the anti-Xa test is used.
How is the sample collected for testing?
A blood sample is obtained by inserting a needle into a vein in the arm, most commonly taken three to four hours after your heparin injection to check the ‘peak’ level.
Is any test preparation needed to ensure the quality of the sample?
No test preparation is needed other than correct timing.
How is it used?
Anti-Xa tests are sometimes requested to monitor and adjust unfractionated heparin (UFH) concentrations in the blood, though the primary monitoring tool for UFH is currently the APTT (or ACT for cardiopulmonary bypass). Anti-Xa may be used to monitor some patients who have “heparin resistance” – do not respond as expected to UFH – or who have an underlying condition or interfering factor(s) that alter the APTT and ACT test result.
Low molecular weight heparin (LMWH) therapy is usually not monitored, but doctors may request anti-Xa tests in some cases. These include patients who are pregnant, obese, very young, elderly and those who have kidney disease. LMWH is primarily cleared from the body by the kidneys. Any condition that decreases kidney function can potentially decrease LMWH clearance, increasing its concentration in the blood and increasing the potential for excessive bleeding.
When is it requested?
The anti-Xa test is not routinely requested but may be performed whenever a doctor wants to evaluate UFH or LMWH concentrations in the blood.
When it is used as a LMWH monitoring tool, anti-Xa is primarily requested as a “peak” test. It is collected about 3-4 hours after a LMWH dose is given, when the concentration of LMWH in the blood is expected to be at its highest level. Random and “trough” anti-Xa tests may also be requested when a doctor suspects that a patient may not be clearing the LMWH at a normal rate. Trough tests are collected just prior to the next dose, when heparin concentrations are expected to be at their lowest.
What does the test result mean?
Anti-Xa results must be evaluated in the context of the type of heparin that a person is receiving (UFH or LMWH and type of LMWH), the timing of the sample collection, and the condition that the person is being treated for. Results from different laboratories may not be interchangeable. Therapeutic reference ranges and the heparins that they are based on vary.
In general, for UFH and LMWH, if concentrations are within an established therapeutic range and the patient is doing well clinically – not clotting, bleeding excessively, or experiencing other complications – then the dosage is considered appropriate. If the anti-Xa concentration is high, then the patient may be getting an excessive dose and/or not be clearing the drug at an expected rate and may be at an increased risk for excessive bleeding.
If the anti-Xa concentration is below the therapeutic range, then the dosage of heparin may need to be increased. When a person is not taking heparin, anti-Xa concentrations should be zero or undetectable.
Is there anything else I should know?
How long will I have to take heparin?
UFH therapy is usually used for short periods of time to help treat and prevent inappropriate clotting. LMWH can be used for short or long periods. When long-term anticoagulation is required, other oral anticoagulants are commonly used unless LMWH is considered the best option (eg. in pregnancy or if there is a diagnosis of cancer).
Do I need to tell my other doctors that I am receiving LMWH?