The BSH Guidelines Official Podcast

Presenters: Sean Platton (Consultant Biomedical Scientist) and Peter Baker (Clinical Scientist and the Laboratory Lead for Haemostasis)

Measurement of heparin, direct oral anti-coagulants and other non-coumarin anti-coagulants and their effects on haemostasis assays: A British Society for Haematology Guideline

This guideline aims to update healthcare professionals working in the UK on the measurement of anti-coagulants (other than coumarins) currently licensed for use in the UK, and their effects on laboratory assays (Table 1). It provides recommendations based on the body of literature produced since the previous guidance published in 2014.1 Direct factor (F)XIa- and direct FXIIa-inhibiting anti-coagulants are at various stages of development but not yet licensed, so are not discussed in this guideline.2 The recent guidelines from the International Society of Thrombosis and Haemostasis Scientific Standardization Committee (ISTH/SSC) on the nomenclature to be used when describing non-vitamin K anti-coagulation3 are followed.

Some anti-coagulants, such as unfractionated heparin (UFH) and argatroban, have been in clinical use for decades. Laboratory monitoring to guide dose adjustments has been with the widely available activated partial thromboplastin time (APTT). However, the COVID-19 pandemic highlighted the wide variability in the sensitivity of different APTT reagents in patients with acute illness, emphasising the need for accessible and cost-effective anti-FIIa and anti-FXa assays for routine monitoring.

The introduction of specific anti-FIIa or anti-FXa-based assays has provided a means to quantitate plasma drug concentrations of the newer fixed-dose FIIa inhibitors (FIIaI) and FXa inhibitors (FXaI). When used according to licence, monitoring these direct oral anti-coagulants (DOACs) is not required, but measuring drug concentration can add value in some circumstances (Table 2). As neither drug concentration nor dose-adjustment based on the measured concentration has yet been shown to affect efficacy or safety, it is incorrect to refer to a therapeutic range. In this manuscript, the term ‘expected range’ is used to acknowledge this limitation.

There are many reports in the literature about the effects of anti-coagulants on measurable parameters of haemostasis. Lack of awareness of these effects, which are variable depending on anti-coagulant, timing of sampling and reagents, can cause confusion and delay diagnosis and care. Table 3 gives a broad overview of the types of impact on laboratory assays that may be seen.

All assays described must be used in accordance with requirements of ISO15189.

In this episode, Professor Graham Collins shares with us the highlights in Hodgkin lymphoma from BSH 2025.  He takes us through the ECHELON-1 trial, which led to the recent NICE approval of Brentuximab-AVD as a frontline treatment option for advanced stage Hodgkin lymphoma.

Professor Graham Collins discusses the management of primary mediastinal B-cell lymphoma, from initial treatment considerations to the management of relapsed disease.

Professor Collins is a Consultant Haematologist and the lymphoma lead clinician at the Oxford Cancer and Haematology Centre.  He has particular interests in Hodgkin and high-grade non-Hodgkin lymphoma and he chairs the national CAR-T panel for lymphoma.

Please note that since the recording of this podcast in December 2024, NICE has granted approval for the use of Liso-cel as a second-line treatment option in primary mediastinal B-cell lymphoma.

Dr Sridhar Chaganti discusses the use of bispecific T-cell engagers (BITE’s) in large B-cell lymphoma.  

Dr Chaganti is a consultant haematologist at University Hospitals Birmingham NHS Foundation Trust. He has a PhD in cancer studies from the University of Birmingham.

His research interest is Epstein–Barr virus (EBV) and lymphomas. His special interests are in haematological malignancies, lymphomas, stem cell transplantation and cellular therapies.

Dr Nikesh (Nik) Chavda discusses supportive care in lymphoma.

Dr Chavda is a haematology consultant at University Hospitals Bristol and Weston, with an interest in B-cell malignancies, cellular therapies and histiocytic disorders.

Dr Duncan Murray discusses mycosis fungoides and sezary syndrome.

Dr Murray completed his PhD at the University of Birmingham, looking at the interaction between the immune system and malignant T cells in skin lymphoma.

He finds the interaction between a "good" and "bad" T cell fascinating. He has used multiple single-cell laboratory techniques to tease apart the two populations (including V-beta antibodies, single-cell T-cell receptor (TCR) and ribonucleic acid (RNA) sequencing and mass cytometry).

Skin lymphoma is an unusual disease in that key determinants of the patient's outcome sit very close together. Both anatomically and in phenotype. His current work focuses on what we can learn from high-dimensional single-cell data and the bioinformatic process to assist this.

Dr Matthew Ahearne is a consultant haematologist at University Hospitals of Leicester NHS Trust. His main clinical and research focus is on T-cell lymphomas.

Dr Ahearne is Deputy Chair of the National Cancer Research Institute (NCRI) T-cell lymphoma working group and an NCRI Lymphoma Science sub-group member.

Dr Sridhar Chaganti discusses the current management of post-transplant lymphoproliferative disorder (PTLD), including subtypes, prognostic factors and the current treatment options.

He explores the role of immunotherapy, cytotoxic agents and the emerging field of cellular therapies in this group of patients.

Dr Chaganti is a consultant haematologist at University Hospitals Birmingham NHS Foundation Trust. He has a PhD in cancer studies from the University of Birmingham.

His research interest is Epstein–Barr virus (EBV) and lymphomas. His special interests are in haematologic malignancies, lymphomas and stem cell transplantation.