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Choi PYI, Uzun G, Bakchoul T. Results of an international survey of opinions on the definitions and treatments for heparin-induced thrombocytopenia: communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost 2024; 22:1772-1778. [PMID: 38301999 DOI: 10.1016/j.jtha.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/08/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is rare, affecting fewer than 1 in 1500 hospital admissions. Despite the increasing adoption of new therapies in HIT, such as direct oral anticoagulants and pooled immunoglobulins, there is limited high-quality evidence to guide clinicians. Numerous uncommon presentations of HIT and HIT-like entities have recently been recognized, and a harmonized approach to their classification is required to study them better. We present the results of an international survey of opinions from experts and practitioners in the field of platelet immunology regarding the role of direct oral anticoagulants in HIT, novel definitions of subclassifications of HIT-like platelet factor 4 immune conditions (spontaneous autoimmune HIT, persistent autoimmune HIT, and treatment-refractory HIT), and the role for intravenous immunoglobulins in the treatment paradigm of HIT and these HIT-like conditions. From 102 survey responses, there was broad acceptance of rivaroxaban (74.5%) and apixaban (73.5%) even before platelet recovery, as well as for intravenous immunoglobulin in the management of spontaneous (85.6%), persistent (83.7%), and treatment-refractory HIT (87.4%). With this mandate for harmonizing terminologies and treatment approaches in special situations without robust clinical data owing to their rarity, we plan to conduct a robust survey, establish international consensus, and draft management guidelines for HIT and platelet factor 4 immune diseases in the near future.
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MESH Headings
- Humans
- Heparin/adverse effects
- Heparin/immunology
- Immunoglobulins, Intravenous/therapeutic use
- Immunoglobulins, Intravenous/adverse effects
- Thrombocytopenia/chemically induced
- Thrombocytopenia/immunology
- Thrombocytopenia/diagnosis
- Anticoagulants/adverse effects
- Platelet Factor 4/immunology
- Surveys and Questionnaires
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Blood Platelets/immunology
- Blood Platelets/drug effects
- Blood Platelets/metabolism
- Pyridones/adverse effects
- Pyridones/therapeutic use
- Rivaroxaban/adverse effects
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Health Care Surveys
- Terminology as Topic
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Affiliation(s)
- Philip Young-Ill Choi
- Haematology Department, the Canberra Hospital, Garran, Canberra, Australian Capital Territory, Australia; John Curtin School of Medical Research, Australian National University, Acton, Canberra, Australian Capital Territory, Australia
| | - Günalp Uzun
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany.
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Porres-Aguilar M, Najera C, Mares AC, Benzidia I, Prakash S, Crichi B. Successful Treatment With the Oral Factor Xa Inhibitor Edoxaban in Heparin-Induced Thrombocytopenia With Thrombosis. Angiology 2023:33197231225291. [PMID: 38153027 DOI: 10.1177/00033197231225291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Heparin-induced thrombocytopenia with thrombosis (HITT) is a rare immune reaction to the drug heparin that causes increased blood clotting, putting patients at risk for arterial and venous thromboembolism which can have severe consequences. We present a case of HITT successfully treated with the direct oral anticoagulant (DOAC), edoxaban. A 56-year-old man had surgery to remove a colorectal mass. After discharge, he developed chest discomfort, shortness of breath, and low oxygen levels and was diagnosed with a right-sided lobar pulmonary embolism. His platelet count dropped, his tests confirmed a diagnosis of HITT, and he was initially treated with fondaparinux. After showing clinical and laboratory improvement, he was switched to edoxaban. Despite being diagnosed with colonic adenocarcinoma during follow-up, the patient's platelet count returned to normal, and he did not experience any more blood clots or serious bleeding events. The use of DOACs like edoxaban as potential therapies for HITT is promising; further research is being conducted to evaluate their effectiveness, safety, and potential benefits for treating this acquired high-risk thrombophilia.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Carolina Najera
- Department of Internal Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA
| | | | - Ilham Benzidia
- Vascular Medicine Unit, Department of Thoracic, Cardiovascular Surgery and Vascular Medicine, CHU Reunion-Site Nord, Saint Denis, France
| | - Swathi Prakash
- Department of Internal Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Renna SA, Zhao X, Kunapuli SP, Ma P, Holinstat M, Boxer MB, Maloney DJ, Michael JV, McKenzie SE. Novel Strategy to Combat the Procoagulant Phenotype in Heparin-Induced Thrombocytopenia Using 12-LOX Inhibition. Arterioscler Thromb Vasc Biol 2023; 43:1808-1817. [PMID: 37345522 DOI: 10.1161/atvbaha.123.319434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a major concern for all individuals that undergo cardiac bypass surgeries or require prolonged heparin exposure. HIT is a life- and limb-threatening adverse drug reaction with an immune response following the formation of ultra-large immune complexes that drive platelet activation through the receptor FcγRIIA. Thrombotic events remain high following the standard of care treatment with anticoagulants, while increasing risk of bleeding complications. This study sought to investigate a novel approach to treatment of HIT. Recent reports demonstrate increased procoagulant activity in HIT; however, these reports required analysis ex vivo, and relevance in vivo remains unclear. METHODS Using human and mouse model systems, we investigated the cooperativity of PARs (protease-activated receptors) and FcγRIIA in HIT. We challenged humanized FcγRIIA transgenic mice with or without endogenous mouse Par4 (denoted as IIA-Par4+/+ or IIA-Par4-/-, respectively) with a well-established model IgG immune complex (anti [α]-CD9). Furthermore, we assessed the procoagulant phenotype and efficacy to treat HIT utilizing inhibitor of 12-LOX (12[S]-lipoxygenase), VLX-1005, previously reported to decrease platelet activation downstream of FcγRIIA and PAR4, using the triple allele HIT mouse model. RESULTS IIA-Par4+/+ mice given αCD9 were severely thrombocytopenic, with extensive platelet-fibrin deposition in the lung. In contrast, IIA-Par4-/- mice had negligible thrombocytopenia or pulmonary platelet-fibrin thrombi. We observed that pharmacological inhibition of 12-LOX resulted in a significant reduction in both platelet procoagulant phenotype ex vivo, and thrombocytopenia and thrombosis in our humanized mouse model of HIT in vivo. CONCLUSIONS These data demonstrate for the first time the need for dual platelet receptor (PAR and FcγRIIA) stimulation for fibrin formation in HIT in vivo. These results extend our understanding of HIT pathophysiology and provide a scientific rationale for targeting the procoagulant phenotype as a possible therapeutic strategy in HIT.
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Affiliation(s)
- Stephanie A Renna
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
| | - Xuefei Zhao
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
| | - Satya P Kunapuli
- Sol Sherry Thrombosis Center and the Department of Physiology, Temple University School of Medicine, Philadelphia, PA (S.P.K.)
| | - Peisong Ma
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
| | - Michael Holinstat
- Department of Pharmacology, University of Michigan, Ann Arbor (M.H.)
| | | | | | - James V Michael
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
| | - Steven E McKenzie
- The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA (S.A.R., X.Z., P.M., J.V.M., S.E.M.)
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Zhao KN, Masci P, Dimeski G, Johnson L, Grant M, de Jersey J, Lavin MF. Potential Application of Recombinant Snake Prothrombin Activator Ecarin in Blood Diagnostics. Biomolecules 2022; 12:1704. [PMID: 36421717 PMCID: PMC9687618 DOI: 10.3390/biom12111704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 08/30/2023] Open
Abstract
We describe here the purification and cloning of a codon-optimized form of the snake prothrombin activator ecarin from the saw scaled viper (Echis carinatus) expressed in mammalian cells. Expression of recombinant ecarin (rEcarin) was carried out in human embryonic kidney cells (HEK) cells under conditions for the development and performance of a novel and scalable recombinant snake ecarin to industry standards. Clotting performance of the rEcarin was established in recalcified citrated whole blood, plasma, and fresh whole blood and found to be comparable to native ecarin (N-Ecarin). Furthermore, hemolysis was observed with N-Ecarin at relatively high doses in both recalcified citrated and fresh whole blood, while clotting was not observed with rEcarin, providing an important advantage for the recombinant form. In addition, rEcarin effectively clotted both recalcified citrated whole blood and fresh whole blood containing different anticoagulants including heparin, warfarin, dabigatran, Fondaparinux, rivaroxaban and apixaban, forming firm clots in the blood collection tubes. These results demonstrate that rEcarin efficiently clots normal blood as well as blood spiked with high concentrations of anticoagulants and has great potential as an additive to blood collection tubes to produce high quality serum for analyte analysis in diagnostic medicine.
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Affiliation(s)
- Kong-Nan Zhao
- Australian Institute of Biotechnology and Nanotechnology, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
- Centre for Kidney Disease Research-Venomics Research, School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Paul Masci
- Centre for Kidney Disease Research-Venomics Research, School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Goce Dimeski
- Chemical Pathology, Princess Alexandra Hospital, Woolloongabba, Brisbane, QLD 4102, Australia
- School of Chemistry and Molecular Biosciences, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Lambro Johnson
- Australian Institute of Biotechnology and Nanotechnology, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Michael Grant
- Q-Sera Pty Ltd., Level 9, 31 Queen St, Melbourne, VIC 3000, Australia
| | - John de Jersey
- School of Chemistry and Molecular Biosciences, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Martin F. Lavin
- Australian Institute of Biotechnology and Nanotechnology, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
- Centre for Clinical Research, RBWH Campus, The University of Queensland, Brisbane, QLD 4029, Australia
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