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Abstract
PURPOSE OF REVIEW Thrombocytopenia and heparin exposure are common in critically ill patients, yet immune heparin-induced thrombocytopenia (HIT), a prothrombotic adverse effect of heparin, rarely accounts for thrombocytopenia in this patient population. The review discusses the clinical and laboratory features that distinguish HIT from non-HIT thrombocytopenia. RECENT FINDINGS The frequency of HIT in heparin-exposed critically ill patients is approximately 0.3-0.5% versus at least a 30-50% background frequency of non-HIT thrombocytopenia. Most patients who form anti-PF4/heparin antibodies do not develop HIT, contributing to HIT overdiagnosis. Disseminated intravascular coagulation (DIC), particularly in the setting of cardiogenic or septic shock associated with 'shock liver', can cause ischemic limb gangrene with pulses, mimicking a clinical picture of HIT. However, whereas non-HIT-related DIC with microthrombosis can be treated with heparin, HIT usually requires nonheparin anticoagulation. HIT-associated DIC can result in an elevated INR, which could reflect factor VII depletion because of extrinsic (tissue factor) pathway-mediated activation of coagulation. SUMMARY Greater understanding of the various clinical and laboratory features that distinguish HIT from non-HIT thrombocytopenia could help improve outcomes in patients who develop thrombocytopenia and coagulopathies in the ICU.
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Chen LD, Roberts AJ, Dager WE. Safety and efficacy of starting warfarin after two consecutive platelet count rises in heparin-induced thrombocytopenia. Thromb Res 2016; 144:229-33. [PMID: 27241355 DOI: 10.1016/j.thromres.2016.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 05/18/2016] [Accepted: 05/19/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Current guidelines on the treatment of heparin-induced thrombocytopenia (HIT) recommend warfarin initiation when platelet levels recover to 150×10(9)/L or more. However, many patients may not achieve this platelet level or may have slow platelet recovery. The aim of this study is to determine if initiating warfarin when platelets start trending upward instead of at a specific level is safe and effective in patients diagnosed with HIT. MATERIALS AND METHODS Two groups of patients diagnosed and treated for HIT in a tertiary care hospital were assessed for HIT-related outcomes: 28 patients had warfarin initiated after platelets recovered to 150×10(9)/L or more and 30 patients had warfarin initiated prior to platelet recovery. RESULTS There was no significant difference between the rate of thrombosis, venous limb gangrene, or limb amputation. Three patients died during the data collection period, all deemed to be unrelated to HIT by independent investigators. The average hospital length of stay was 22.2±12.7days and 38.8±19.1days for patients who started warfarin at platelets less than 150×10(9)/L and platelets greater than or equal to 150×10(9)/L respectively (P=0.0002). CONCLUSIONS The data suggests that the absolute platelet level at which warfarin is initiated does not affect the rate of thrombosis or mortality but may shorten overall hospital length of stay and associated costs. Therefore, it may be more important to observe an upward trend in platelets rather than striving to achieve an absolute platelet level before starting warfarin in patients with HIT.
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Affiliation(s)
- Lydia D Chen
- Department of Pharmacy, University of California Davis Medical Center, United States
| | - A Josh Roberts
- Department of Pharmacy, University of California Davis Medical Center, United States
| | - William E Dager
- Department of Pharmacy, University of California Davis Medical Center, United States.
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Skelley JW, Kyle JA, Roberts RA. Novel oral anticoagulants for heparin-induced thrombocytopenia. J Thromb Thrombolysis 2016; 42:172-8. [DOI: 10.1007/s11239-016-1365-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Cuker A. Management of the multiple phases of heparin-induced thrombocytopenia. Thromb Haemost 2016; 116:835-842. [PMID: 27075525 DOI: 10.1160/th16-02-0084] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/27/2016] [Indexed: 01/01/2023]
Abstract
The clinical course of heparin-induced thrombocytopenia (HIT) may be separated into five sequential phases: 1. suspected HIT, 2. acute HIT, 3. subacute HIT A, 4. subacute HIT B, and 5. remote HIT. Each phase confronts the clinician with a unique set of management questions. In this review, the phases of HIT are defined and key management questions associated with each phase are discussed. Among patients with Suspected HIT, I use the 4Ts score to determine which patients have a sufficiently high probability of HIT to justify discontinuation of heparin and initiation of a non-heparin parenteral anticoagulant. An algorithm for selecting an appropriate non-heparin anticoagulant based on the patient's clinical stability, renal and hepatic function, drug availability, and physician comfort is provided. In patients with Acute HIT, I generally avoid prophylactic platelet transfusion and inferior vena cava filter insertion because of a potential increased risk of thrombosis. I perform 4-limb screening compression ultrasonography. In patients with symptomatic thromboembolism or asymptomatic proximal deep-vein thrombosis, I treat with anticoagulation for three months. In patients without thrombosis, I discontinue anticoagulation upon platelet count recovery. I do not transition patients to an oral anticoagulant until platelet count recovery (i. e. Subacute HIT A). I increasingly choose direct oral anticoagulants over vitamin K antagonists in this setting because of their greater convenience and safety. In Subacute HIT B and Remote HIT, I use heparin for cardiovascular surgery, whereas I use bivalirudin in patients with Acute HIT and Subacute HIT A in whom surgery cannot be delayed.
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Affiliation(s)
- Adam Cuker
- Adam Cuker, MD, MS, Penn Comprehensive Hemophilia and Thrombosis Program, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA, Tel.: +1 215 615 6555, Fax: +1 215 615 6599, E-mail:
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Bakchoul T. An update on heparin-induced thrombocytopenia: diagnosis and management. Expert Opin Drug Saf 2016; 15:787-97. [DOI: 10.1517/14740338.2016.1165667] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Tamam Bakchoul
- Institute for Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
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Warkentin TE, Pai M. Shock, acute disseminated intravascular coagulation, and microvascular thrombosis: is 'shock liver' the unrecognized provocateur of ischemic limb necrosis? J Thromb Haemost 2016; 14:231-5. [PMID: 26662371 DOI: 10.1111/jth.13219] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 11/25/2015] [Indexed: 11/29/2022]
Abstract
For unknown reasons, a small minority of critically ill patients with septic or cardiogenic shock, multiorgan failure, and disseminated intravascular coagulation develop symmetrical acral (distal extremity) limb loss due to microvascular thrombosis ('limb gangrene with pulses'). Case reports have described preceding 'shock liver' in some critically ill patients who developed such a picture of ischemic limb necrosis. This suggests that profoundly disturbed procoagulant-anticoagulant balance featuring uncontrolled generation of thrombin-resulting from failure of the protein C and antithrombin natural anticoagulant systems due to insufficient hepatic synthesis of these crucial proteins-could explain the microvascular thrombosis and associated limb loss. We hypothesize that shock liver is the key predisposing risk factor underlying ischemic limb necrosis in the majority of patients who develop this complication in the setting of acute disseminated intravascular coagulation complicating septic or cardiogenic shock. As shock liver precedes onset of limb ischemia by several days, therapeutic intervention may be possible.
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Affiliation(s)
- T E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Pai
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
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Smythe MA, Priziola J, Dobesh PP, Wirth D, Cuker A, Wittkowsky AK. Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism. J Thromb Thrombolysis 2016; 41:165-86. [PMID: 26780745 PMCID: PMC4715846 DOI: 10.1007/s11239-015-1315-2] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Venous thromboembolism (VTE) is a serious and often fatal medical condition with an increasing incidence. Despite the changing landscape of VTE treatment with the introduction of the new direct oral anticoagulants many uncertainties remain regarding the optimal use of traditional parenteral agents. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance based on existing guidelines and consensus expert opinion where guidelines are lacking. This specific chapter addresses the practical management of heparins including low molecular weight heparins and fondaparinux. For each anticoagulant a list of the most common practice related questions were created. Each question was addressed using a brief focused literature review followed by a multidisciplinary consensus guidance recommendation. Issues addressed included initial anticoagulant dosing recommendations, recommended baseline laboratory monitoring, managing dose adjustments, evidence to support a relationship between laboratory tests and meaningful clinical outcomes, special patient populations including extremes of weight and renal impairment, duration of necessary parenteral therapy during the transition to oral therapy, candidates for outpatient treatment where appropriate and management of over-anticoagulation and adverse effects including bleeding and heparin induced thrombocytopenia. This article concludes with a concise table of clinical management questions and guidance recommendations to provide a quick reference for the practical management of heparin, low molecular weight heparin and fondaparinux.
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Affiliation(s)
| | | | - Paul P Dobesh
- University of Nebraska Medical Center College of Pharmacy, Omaha, NE, USA
| | | | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ann K Wittkowsky
- University of Washington School of Pharmacy, 1959 NE Pacific St Box 356015, Seattle, WA, 98195, USA.
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Tardy-Poncet B, Nguyen P, Thiranos JC, Morange PE, Biron-Andréani C, Gruel Y, Morel J, Wynckel A, Grunebaum L, Villacorta-Torres J, Grosjean S, de Maistre E. Argatroban in the management of heparin-induced thrombocytopenia: a multicenter clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:396. [PMID: 26556106 PMCID: PMC4641392 DOI: 10.1186/s13054-015-1109-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 10/17/2015] [Indexed: 11/28/2022]
Abstract
Introduction The aim of this study was to collect data in France in patients with heparin-induced thrombocytopenia who required parenteral anticoagulation and for whom other non-heparin anticoagulant therapies were contraindicated including patients with renal failure, cross-reactivity to danaparoid or at high hemorrhagic risk. Methods A total of 20 patients, of mean age 72 ± 10 years, were enrolled in this open-label, multicenter clinical study. Exploratory statistical data analysis was performed with descriptive interpretation of intra-individual comparisons using simple univariate statistics. Results The diagnosis of HIT was confirmed in 16 subjects by an independent scientific committee. Fourteen patients (70 %) were in an intensive care unit during the course of the study. Patients were treated with argatroban for a mean duration of 8.5 ± 6.1 days. The mean starting dose of argatroban was 0.77 ± 0.45 μg/kg/min. Platelet recovery was rapid. aPTT and anti-IIa activity assays were used to monitor the dose of argatroban. The mean baseline aPTT value was 45.0 ± 9.8 sec and increased to 78.2 ± 35.8 sec two hours after initiating argatroban. At this time mean argatroban concentration was 0.34 ± 0.16 and 0.61 ± 0.28 μg/ml using ECT and TT measurements, respectively. New and/or extended thromboses were reported in 25 % of patients and major bleedings were documented in 15 %. Six patients died due to their underlying medical condition. Conclusion Considering its hepatic elimination and its short half-life, argatroban can be considered as a safe therapeutic option in HIT patients at high hemorrhagic risk and with renal failure, particularly in an ICU setting.
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Affiliation(s)
- Brigitte Tardy-Poncet
- EA 3065, Université Jean-Monnet, INSERM CIC 1408 - FCRIN-INNOVTE - Laboratory of Hematology, University Hospital of St Etienne, St Etienne, France.
| | - Philippe Nguyen
- Laboratory of Hematology, University Hospital of Reims, Reims, France.
| | - Jean-Claude Thiranos
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France.
| | | | | | - Yves Gruel
- Laboratory of Hematology, University Hospital of Tours, Tours, France.
| | - Jérome Morel
- Department of Intensive Care Unit, University Hospital of St Etienne, St Etienne, France.
| | | | - Lelia Grunebaum
- Laboratory of Hematology, University Hospitals of Strasbourg, Strasbourg, France.
| | | | - Sandrine Grosjean
- Intensive Care Medicine, University Hospital of Dijon, Dijon, France.
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Smythe MA, Forsyth LL, Warkentin TE, Smith MD, Sheppard JAI, Shannon F. Progressive, Fatal Thrombosis Associated With Heparin-Induced Thrombocytopenia After Cardiac Surgery Despite “Therapeutic” Anticoagulation With Argatroban: Potential Role for PTT and ACT Confounding. J Cardiothorac Vasc Anesth 2015; 29:1319-21. [DOI: 10.1053/j.jvca.2014.04.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Indexed: 01/25/2023]
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Linkins LA, Warkentin TE. Rivaroxaban for treatment of HIT: A riveting first experience. Thromb Res 2015; 135:1-2. [DOI: 10.1016/j.thromres.2014.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 10/24/2014] [Accepted: 10/24/2014] [Indexed: 11/15/2022]
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Warkentin TE. Voting with your fondaparinux. Thromb Res 2014; 134:3-4. [DOI: 10.1016/j.thromres.2014.03.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 03/26/2014] [Accepted: 03/26/2014] [Indexed: 01/29/2023]
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Kopolovic I, Warkentin TE. Progressive thrombocytopenia after cardiac surgery in a 67-year-old man. CMAJ 2014; 186:929-33. [PMID: 24756626 DOI: 10.1503/cmaj.131449] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Ilana Kopolovic
- Department of Medicine (Kopolovic), University of Toronto, Toronto, Ont.; Pathology and Molecular Medicine (Warkentin), Hamilton Regional Laboratory Medicine Program, McMaster University, Hamilton, Ont.
| | - Theodore E Warkentin
- Department of Medicine (Kopolovic), University of Toronto, Toronto, Ont.; Pathology and Molecular Medicine (Warkentin), Hamilton Regional Laboratory Medicine Program, McMaster University, Hamilton, Ont
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Schindewolf M, Steindl J, Beyer-Westendorf J, Schellong S, Dohmen PM, Brachmann J, Madlener K, Pötzsch B, Klamroth R, Hankowitz J, Banik N, Eberle S, Kropff S, Müller MM, Lindhoff-Last E. Frequent off-label use of fondaparinux in patients with suspected acute heparin-induced thrombocytopenia (HIT)--findings from the GerHIT multi-centre registry study. Thromb Res 2014; 134:29-35. [PMID: 24703295 DOI: 10.1016/j.thromres.2014.03.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/05/2014] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION In life-threatening immune heparin-induced thrombocytopenia (HIT), treatment with an approved non-heparin anticoagulant is essential. However, off-label use with fondaparinux has been reported in the literature. The study aim was to collect data on "real-life" management of patients with suspected acute HIT regarding diagnostic and therapeutic strategies. PATIENTS AND METHODS In a national multi-centre registry study, patients with a 4T's HIT-probability score of ≥ 4 points and treatment with at least one dose of (A)rgatroban, (L)epirudin, (D)anaparoid, or (F)ondaparinux were retrospectively evaluated. RESULTS Of 195 patients, the 4T's scores were 4/5/6/7/8 points in 46 (23.6%)/50 (25.6%)/74 (38.0%)/13 (6.7%)/7 (3.6%) patients, respectively. During heparin therapy, 47 (24.1%) thromboembolic events, 5 (2.6%) skin lesions, 1 (0.5%) amputation, 24 (12.3%) Hb-relevant bleedings, and 2 (1.0%) fatalities occurred. A functional heparin-induced platelet activation assay was performed in 96.9%, a platelet factor 4/heparin-dependent enzyme immunoassay in 89.2%, a particle gel immunoassay in 12.3%, and a serotonin-release assay in none of the patients. Argatroban was used in 16.4%, lepirudin in 2.1%, danaparoid in 23.6%, fondaparinux in 40.0% of the patients; the sequential therapy strata were: AF (5.6%), DA (5.6%), DF (2.6%), DL (2.1%), ADF (1.5%), and DFL (0.5%). CONCLUSIONS The current diagnostic laboratory strategy for suspected HIT is mostly (>96%) based on the recommended 2-step strategy (immunoassay plus functional assay). However, there is a wide fondaparinux off-label use (up to 50.3%) for suspected HIT, even in those patients with a high clinical pretest probability. Efficacy and safety of fondaparinux for HIT-treatment require further evaluation.
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Affiliation(s)
- Marc Schindewolf
- Department of Internal Medicine, Division of Vascular Medicine/Haemostaseology, Goethe University Hospital, Frankfurt/M., Germany.
| | - Julia Steindl
- Department of Internal Medicine, Division of Vascular Medicine/Haemostaseology, Goethe University Hospital, Frankfurt/M., Germany
| | - Jan Beyer-Westendorf
- Department of Medicine III, Division of Angiology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Sebastian Schellong
- Medical Department II, Municipal Hospital Dresden Friedrichstadt, Dresden, Germany
| | - Pascal Maria Dohmen
- Department of Cardiovascular Surgery, Charité Hospital, Medical University Berlin, Berlin, Germany
| | - Johannes Brachmann
- II. Medical Clinic, Department of Cardiology, Klinikum Coburg, Coburg, Germany
| | - Katharina Madlener
- Department of Haemostaseology and Transfusion Medicine, Kerckhoff-Klinik, Bad Nauheim, Germany
| | - Bernd Pötzsch
- Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Robert Klamroth
- Department of Internal Medicine, Haemophilia Treatment Centre, Vivantes Klinikum im Friedrichshain Berlin, Berlin, Germany
| | | | - Norbert Banik
- GlaxoSmithKline, Biostatistics & Epidemiology, München, Germany
| | - Sonja Eberle
- GlaxoSmithKline, Biostatistics & Epidemiology, München, Germany
| | - Stefan Kropff
- GlaxoSmithKline, Cardiovascular and Antithrombotics, München, Germany
| | | | - Edelgard Lindhoff-Last
- Department of Internal Medicine, Division of Vascular Medicine/Haemostaseology, Goethe University Hospital, Frankfurt/M., Germany
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Linkins LA, Warkentin TE, Pai M, Shivakumar S, Manji RA, Wells PS, Crowther MA. Design of the rivaroxaban for heparin-induced thrombocytopenia study. J Thromb Thrombolysis 2014; 38:485-92. [DOI: 10.1007/s11239-014-1064-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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