Tirofiban-Induced Severe Thrombocytopenia

An Updated Comprehensive Pharmacovigilance Study of Drug-Induced Thrombocytopenia Based on FDA Adverse Event Reporting System Data

Drug-induced thrombocytopenia (DIT) deserves both clinical and research attention for the serious clinical consequences and high prevalence of the condition. The current study aimed to perform a comprehensive pharmacovigilance analysis of DIT reported in the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database, with a particular focus on drugs associated with thrombocytopenia events. A disproportionality analysis of DIT was conducted using reports submitted to FARES from January 2004 to December 2022. Both the information component (IC) and reporting odds ratio (ROR) algorithms were applied to identify an association between target drugs and DIT events. A total of 15,940,383 cases were gathered in FAERS, 168,657 of which were related to DIT events. The top 50 drugs ranked by number of cases and ranked by signal strength were documented. The top 5 drugs ranked by number of cases were lenalidomide (10,601 cases), niraparib (3726 cases), ruxolitinib (3624 cases), eltrombopag (3483 cases), and heparin (3478 cases). The top 5 drugs ranked by signal strength were danaparoid (ROR 37.61, 95%CI 30.46-46.45), eptifibatide (ROR 34.75, 95%CI 30.65-39.4), inotersen (ROR 34.00, 95%CI 29.47-39.23), niraparib (ROR 30.53, 95%CI 29.42-31.69), and heparin (ROR 28.84, 95%CI 27.76-29.97). The top 3 involved drug groups were protein kinase inhibitors, antimetabolites, and monoclonal antibodies and antibody-drug conjugates. The current comprehensive pharmacovigilance study identified more drugs associated with thrombocytopenia. Although the mechanisms of DIT have been elucidated for some drugs, others still require further investigation.

Tirofiban-induced thrombocytopenia

Tirofiban is a small non-peptide ligand-mimetic Glycoprotein (GP) IIb/IIIa inhibitor which can reversibly bind to the arginine-glycine-aspartic acid (RGD) recognition site of GP IIb/IIIa to prevent platelet aggregation. It reduces the incidence of thrombotic cardiovascular events in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Although generally considered safe, tirofiban has been reported to be associated with thrombocytopenia in several case reports and clinical trials. The pathogenesis for this adverse reaction is not entirely understood, is thought to be due to immune-mediated reaction. This side effect caused by tirofiban is especially concerning given how frequently it is used in the practice of contemporary cardiovascular care. The present review provides an overview of the pathophysiology, clinical presentation, management, and risk factors associated with tirofiban-induced thrombocytopenia.

Severe Acute Thrombocytopenia After Treatment with Tirofiban: A Case Series Approach

Glycoprotein IIb/IIIa inhibitors are an adjuvant therapy for the treatment of patients with acute coronary syndromes. The main adverse reactions are bleeding and thrombocytopenia in 1-2% of cases. A 66-year-old woman arrived at the emergency department with ST-elevation MI. The catheterisation lab was busy, so she received thrombolytic therapy. Coronary angiography revealed a 90% stenosis in the middle segment of the left anterior descending artery and Thrombolysis in MI 2 flow. Subsequent percutaneous coronary intervention showed abundant thrombus and a coronary dissection and it was necessary to insert five drug-eluting stents. Non-fractionated heparin and a tirofiban infusion were used. After the percutaneous coronary intervention, she developed severe thrombocytopenia, haematuria and gingivorrhagia, for which infusion of tirofiban was suspended. In follow-up, no major bleeding or subsequent haemorrhagic complications were identified. It is crucial to distinguish between heparin-induced thrombocytopenia and thrombocytopenia caused by other drugs. A high level of suspicion should be employed in these cases.

Acute profound thrombocytopenia induced by tirofiban in stent assisted embolization of intracranial ruptured aneurysm-a rare case report

Objectives

Glycoprotein (GP) IIb/IIIa receptor antagonists (Tirofiban) are often used as antiplatelet agents in patients undergoing interventional therapy due to acute coronary syndrome and cerebrovascular diseases. Thrombocytopenia is a common complication of GP IIb/IIIa receptor antagonist, with an incidence of 1%-5%, whereas acute profound thrombocytopenia (platelet count<20 × 109/L) is extremely rare. We reported a case of acute profound thrombocytopenia due to tirofiban treatment to inhibit platelet aggregation during and after surgery in a patient who underwent stent-assisted embolization for ruptured intracranial aneurysm.

Case presentation

A 59-year-old female patient, who visited the Emergency Department of our hospital due to sudden headache, vomiting, and unconsciousness for 2 hours. Neurological examination: the patient was unconscious, the pupils on both sides had the same roundness, and the reflection on light was slow. The Hunt-Hess grade was IV. Head CT showed subarachnoid hemorrhage and Fisher's score was 3. We immediately implemented LVIS stent-assisted embolization, intraoperative heparinization, and intraoperative jailing technology to perform dense embolism on aneurysms. The patient was treated with mild hypothermia and Tirofiban 5mL/h intravenous pump. Since then, the patient had developed acute profound thrombocytopenia.

Conclusion

We reported a case of acute profound thrombocytopenia due to tirofiban treatment during and after interventional therapy. For patients after unilateral nephrectomy, we should pay more attention to avoid the occurrence of thrombocytopenia caused by abnormal metabolism of tirofiban, although the Laboratory examination showed normal results.