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Rodrigues AB, Rodrigues A, Correia CJ, Jesus GN, Ribeiro JM. Anticoagulation Management in V-V ECMO Patients: A Multidisciplinary Pragmatic Protocol. J Clin Med 2024; 13:719. [PMID: 38337414 PMCID: PMC10856724 DOI: 10.3390/jcm13030719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/11/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is a complex procedure affecting both the risk of thrombosis and bleeding. High-quality data to personalize anticoagulation management in ECMO are lacking, resulting in a high variability in practice among centers. For this reason, we review coagulation methods and monitoring and share a pragmatic proposal of coagulation management, as performed in our high-volume ECMO Referral Centre; (2) Methods: We revised the anticoagulation options and monitoring methods available for coagulation management in ECMO through PubMed search based on words including "anticoagulation," "coagulation assays," "ECMO," "ELSO," and "ISTH"; (3) Results: Actual revision of the literature was described as our routine practice regarding ECMO anticoagulation and monitoring; (4) Conclusions: No coagulation test is exclusively predictive of bleeding or thrombotic risk in patients undergoing ECMO support. An approach that allows for a tailored regimen of anticoagulation (regardless of agent used) and monitoring is mandatory. To accomplish this, we propose that the titration of anticoagulation therapies should include multiple laboratory tests, including anti-Xa, aPTT, ACT, viscoelastic tests, AT levels, platelet count, fibrinogen, and FXIII levels. Anticoagulation regimens should be tailored to a specific patient and personalized based on this complex array of essays.
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Affiliation(s)
- Ana Bento Rodrigues
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (G.N.J.); (J.M.R.)
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina de Lisboa, 1649-028 Lisboa, Portugal
- ECMO Referral Centre, Intensive Care Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | - Anabela Rodrigues
- Serviço de Imuno-Hemoterapia, Blood Transfusion Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (A.R.); (C.J.C.)
| | - Catarina Jacinto Correia
- Serviço de Imuno-Hemoterapia, Blood Transfusion Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (A.R.); (C.J.C.)
| | - Gustavo Nobre Jesus
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (G.N.J.); (J.M.R.)
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina de Lisboa, 1649-028 Lisboa, Portugal
- ECMO Referral Centre, Intensive Care Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | - João Miguel Ribeiro
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (G.N.J.); (J.M.R.)
- ECMO Referral Centre, Intensive Care Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
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Giles JB, Miller EC, Steiner HE, Karnes JH. Elucidation of Cellular Contributions to Heparin-Induced Thrombocytopenia Using Omic Approaches. Front Pharmacol 2022; 12:812830. [PMID: 35126147 PMCID: PMC8814424 DOI: 10.3389/fphar.2021.812830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/31/2021] [Indexed: 11/23/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an unpredictable, complex, immune-mediated adverse drug reaction associated with a high mortality. Despite decades of research into HIT, fundamental knowledge gaps persist regarding HIT likely due to the complex and unusual nature of the HIT immune response. Such knowledge gaps include the identity of a HIT immunogen, the intrinsic roles of various cell types and their interactions, and the molecular basis that distinguishes pathogenic and non-pathogenic PF4/heparin antibodies. While a key feature of HIT, thrombocytopenia, implicates platelets as a seminal cell fragment in HIT pathogenesis, strong evidence exists for critical roles of multiple cell types. The rise in omic technologies over the last decade has resulted in a number of agnostic, whole system approaches for biological research that may be especially informative for complex phenotypes. Applying multi-omics techniques to HIT has the potential to bring new insights into HIT pathophysiology and identify biomarkers with clinical utility. In this review, we review the clinical, immunological, and molecular features of HIT with emphasis on key cell types and their roles. We then address the applicability of several omic techniques underutilized in HIT, which have the potential to fill knowledge gaps related to HIT biology.
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Affiliation(s)
- Jason B. Giles
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States
| | - Elise C. Miller
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States
| | - Heidi E. Steiner
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States
| | - Jason H. Karnes
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, AZ, United States,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States,*Correspondence: Jason H. Karnes,
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3
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Sun S, Urbanus RT, ten Cate H, de Groot PG, de Laat B, Heemskerk JWM, Roest M. Platelet Activation Mechanisms and Consequences of Immune Thrombocytopenia. Cells 2021; 10:cells10123386. [PMID: 34943895 PMCID: PMC8699996 DOI: 10.3390/cells10123386] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/28/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022] Open
Abstract
Autoimmune disorders are often associated with low platelet count or thrombocytopenia. In immune-induced thrombocytopenia (IIT), a common mechanism is increased platelet activity, which can have an increased risk of thrombosis. In addition, or alternatively, auto-antibodies suppress platelet formation or augment platelet clearance. Effects of the auto-antibodies are linked to the unique structural and functional characteristics of platelets. Conversely, prior platelet activation may contribute to the innate and adaptive immune responses. Extensive interplay between platelets, coagulation and complement activation processes may aggravate the pathology. Here, we present an overview of the reported molecular causes and consequences of IIT in the most common forms of autoimmune disorders. These include idiopathic thrombocytopenic purpura (ITP), systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), drug-induced thrombocytopenia (DITP), heparin-induced thrombocytopenia (HIT), COVID-19 vaccine-induced thrombosis with thrombocytopenia (VITT), thrombotic thrombocytopenia purpura (TTP), and hemolysis, the elevated liver enzymes and low platelet (HELLP) syndrome. We focus on the platelet receptors that bind auto-antibodies, the immune complexes, damage-associated molecular patterns (DAMPs) and complement factors. In addition, we review how circulating platelets serve as a reservoir of immunomodulatory molecules. By this update on the molecular mechanisms and the roles of platelets in the pathogenesis of autoimmune diseases, we highlight platelet-based pathways that can predispose for thrombocytopenia and are linked thrombotic or bleeding events.
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Affiliation(s)
- Siyu Sun
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (S.S.); (H.t.C.)
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
| | - Rolf T. Urbanus
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands;
| | - Hugo ten Cate
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (S.S.); (H.t.C.)
- Maastricht University Medical Center, Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Philip G. de Groot
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
| | - Bas de Laat
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
| | - Johan W. M. Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (S.S.); (H.t.C.)
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
- Correspondence: (J.W.M.H.); (M.R.); Tel.: +31-68-1032534 (J.W.M.H. & M.R.)
| | - Mark Roest
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (S.S.); (H.t.C.)
- Synapse Research Institute, 6217 KD Maastricht, The Netherlands; (P.G.d.G.); (B.d.L.)
- Correspondence: (J.W.M.H.); (M.R.); Tel.: +31-68-1032534 (J.W.M.H. & M.R.)
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Anticoagulation with Argatroban in a Patient with Heparin-Induced Thrombocytopenia and Renal Insufficiency Undergoing Orthotopic Heart Transplantation. Case Rep Anesthesiol 2021; 2021:9945225. [PMID: 34691786 PMCID: PMC8528599 DOI: 10.1155/2021/9945225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/25/2021] [Accepted: 10/06/2021] [Indexed: 11/17/2022] Open
Abstract
Unfractionated heparin is the anticoagulant of choice for cardiac surgery that requires cardiopulmonary bypass. However, it can cause serious side effects like heparin-induced thrombocytopenia (HIT), an immune-mediated process where antibodies are directed against heparin and platelet 4 complexes. In such cases, alternative pharmacologic strategies are implemented to facilitate safe bypass conditions. A woman with severe decompensated heart failure was heparinized for intra-aortic balloon pump and subsequent LVAD placement. On day 6, a fall in platelets from 113,000 to 26,000 was noted. She was diagnosed with HIT. Heparin was discontinued and replaced with an argatroban infusion for the duration of her care until heart transplantation was completed. We review the mechanism, diagnosis, and complications of HIT. We discuss cardiopulmonary bypass and its relation to heparin, HIT, and heparin alternatives. We discuss argatroban's relevant pharmacology, clinical use, advantages, and disadvantages.
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Siguret V, Boissier E, Maistre ED, Gouin-Thibault I, James C, Lasne D, Mouton C, Godon A, Nguyen P, Lecompte T, Ajzenberg N, Bauters A, Béjot Y, Crassard I, Dahmani B, Desconclois C, Flaujac C, Frère C, Godier A, Gruel Y, Hézard N, Jourdi G, Kuadjovi C, Laurichesse M, Mémier V, Mourey G, Reiner P, Tardy B, Toussaint-Hacquard M. GFHT Proposals On The Practical Use Of Argatroban - With Specifics Regarding Vaccine-Induced Immune Thrombotic Thrombocytopaenia (VITT). Anaesth Crit Care Pain Med 2021; 40:100963. [PMID: 34673303 DOI: 10.1016/j.accpm.2021.100963] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
Argatroban is a direct anti-IIa (thrombin) anticoagulant, administered as a continuous intravenous infusion; it has been approved in many countries for the anticoagulant management of heparin-induced thrombocytopaenia (HIT). Argatroban was recently proposed as the non-heparin anticoagulant of choice for the management of patients diagnosed with Vaccine-induced Immune Thrombotic Thrombocytopaenia (VITT). Immunoglobulins are also promptly intravenously administered in order to rapidly improve platelet count; concomitant therapy with steroids is also often considered. An ad hoc committee of the French Working Group on Haemostasis and Thrombosis members has worked on updated and detailed proposals regarding the management of anticoagulation with argatroban, based on previously released guidance for HIT, and adapted for VITT. In case of VITT, the initial dose to be preferred is 1.0 µg x kg-1 x min-1, with further dose-adjustments based on iterative and frequent clinical and laboratory assessments. It is strongly advised to involve a health practitioner experienced in the management of difficult cases in haemostasis. The first laboratory assessment should be performed 4 hours after the initiation of argatroban infusion, with further controls at 2-4-hour intervals until steady state, and at least once daily thereafter. Importantly, full anticoagulation should be rapidly achieved in case of widespread thrombosis. Cerebral vein thrombosis (which is typical of VITT) should not call for an overly cautious anticoagulation scheme. Argatroban administration requires baseline laboratory assessment and should rely on an anti-IIa assay to derive argatroban plasma levels using a dedicated calibration, with a target range between 0.5 and 1.5 µg/mL. Target argatroban plasma levels can be refined based on meticulous appraisal of risk factors for bleeding and thrombosis, on frequent reassessments of clinical status with appropriate vascular imaging, and on the changes in daily platelet counts. Regarding the use of aPTT, baseline value and possible causes for alterations of the clotting time must be taken into account. Specifically, in case of VITT, an aPTT ratio (patient's / mean normal clotting time) between 1.5 and 2.5 is suggested, to be refined according to the sensitivity of the reagent to the effect of a direct thrombin inhibitor. The sole use of aPTT is discouraged: one has to resort to a periodical check with an anti-IIa assay at least, with the help of a specialised laboratory if necessary. Dose modifications should proceed in a stepwise manner with 0.1 to 0.2 µg x kg-1 x min-1 up- or downward changes, taking into account the initial dose, laboratory results, and the whole individual setting. Nomograms are available to adjust the infusion rate. Haemoglobin level, platelet count, fibrinogen plasma level and liver tests should be periodically checked, depending on the clinical status, the more so when unstable.
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Affiliation(s)
- Virginie Siguret
- Hématologie biologique - Hôpital Lariboisière (AP-HP), UMR_S1140, Université de Paris, Paris, France.
| | - Elodie Boissier
- Laboratoire d'hématologie, Hôpital Laënnec, CHU de Nantes, France
| | | | | | - Chloé James
- Laboratoire d'hématologie, CHU de Bordeaux, Pessac, France
| | - Dominique Lasne
- Hématologie biologique - Hôpital Necker-Enfants malades (AP-HP), Paris, UMR_S1176 Université Paris Saclay, Le Kremlin Bicêtre, France
| | | | | | | | - Thomas Lecompte
- Départements de médecine, Hôpitaux Universitaires de Genève, Unité d'hémostase, & Faculté de Médecine - GpG, Université de Genève, Genève, Suisse
| | | | - Anne Bauters
- Service d'hématologie et transfusion, Université de Lille, CHU de Lille, Lille, France
| | | | - Isabelle Crassard
- Neurologie, Hôpital Lariboisière (APHP), FHU NeuroVasculaire, Université de Paris, Paris, France
| | - Bouhadjar Dahmani
- Hémostase et Thrombose, Centre Hospitalier Princesse Grace de Monaco, Monaco
| | | | - Claire Flaujac
- Laboratoire de biologie médicale, secteur hémostase, CH de Versailles, Le Chesnay, France
| | - Corinne Frère
- Hématologie Biologique, Hôpital Pitié Salpêtrière (AP-HP); Sorbonne Université, UMRS 1166, Institut hospitalo-universitaire ICAN, Paris, France
| | - Anne Godier
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou (AP-HP), Paris, France
| | - Yves Gruel
- Hématologie biologique, CHU Tours, Tours, France
| | | | - Georges Jourdi
- Centre de recherche, Institut de Cardiologie de Montréal, Faculté de Pharmacie, Université de Montréal, Canada
| | - Charlène Kuadjovi
- Laboratoire du GCS Nord-Ouest Val d'Oise, CH Pontoise, Pontoise, France
| | | | - Vincent Mémier
- Laboratoire d'Hématologie, CHU Toulouse, Toulouse, France
| | - Guillaume Mourey
- Laboratoire d'Hématologie et d'Immunologie, Établissement Français du Sang Bourgogne -Franche-Comté, Besançon, France
| | - Peggy Reiner
- Service d'hématologie et transfusion, Université de Lille, CHU de Lille, Lille, France
| | - Brigitte Tardy
- INSERM U1059, Université J Monnet, Saint Etienne, France
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Chan M, Zhao X, Zheng XL. Low ADAMTS-13 predicts adverse outcomes in hospitalized patients with suspected heparin-induced thrombocytopenia. Res Pract Thromb Haemost 2021; 5:e12581. [PMID: 34553121 PMCID: PMC8444283 DOI: 10.1002/rth2.12581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/13/2021] [Accepted: 07/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a life-threatening thrombotic complication after heparin exposure. However, the role of ADAMTS-13 and von Willebrand factor (VWF) in the disease process and outcomes of HIT is not known. OBJECTIVE To determine the potential role of ADAMTS-13 and VWF in hospitalized patients suspected with HIT. METHODS Associations of the HIT tests, ADAMTS-13 activity, and VWF antigen or activity with other clinical parameters and outcomes in the patients suspected with HIT were determined. RESULTS Of 261 patients, 87 (33.3%) were positive and 174 (66.7%) were negative for a HIT antibody determined by an enzyme immunoassay (EIA). Of these 87 EIA+ patients, 31 (35.6%) were also positive but 56 (64.4%) were negative for serotonin-releasing assay (SRA). There was no statistically significant difference among all three groups (i.e., EIA-, EIA+/SRA+, and EIA+/SRA-) as to their demographic features, reasons for admission to the hospital, type of procedures performed, and in-hospital mortality. Compared to those in the healthy controls, plasma ADAMTS-13 activity in patients suspected with HIT was significantly lower but plasma VWF antigen (VWFAg) and activity (VWFAc) in these patients were significantly higher. While there was no statistically significant difference among all three groups regarding plasma levels of ADAMTS-13 activity, VWFAg, and VWFAc, plasma levels of ADAMTS-13 activity <50% or the low ratios of ADAMTS-13 activity to VWFAg (or VWFAc) are highly predictive for a 90-day mortality rate, particularly in the EIA+SRA+ group. CONCLUSIONS These results demonstrate that relative deficiency of plasma ADAMTS-13 activity in hospitalized patients suspected with HIT is common, which may contribute at least in part to the adverse outcomes in this patient population, particularly in those with true HIT.
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Affiliation(s)
- Meng Chan
- Departments of Pathology and Laboratory MedicineThe University of Kansas Medical CenterKansas CityKSUSA
| | - Xinyang Zhao
- Departments of Biochemistry and Molecular GeneticsThe University of Alabama at BirminghamBirminghamALUSA
| | - X. Long Zheng
- Departments of Pathology and Laboratory MedicineThe University of Kansas Medical CenterKansas CityKSUSA
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Chayoua W, Nicolson PLR, Meijers JCM, Kardeby C, Garcia‐Quintanilla L, Devreese KMJ, de Laat B, Watson SP, de Groot PG. Antiprothrombin antibodies induce platelet activation: A possible explanation for anti-FXa therapy failure in patients with antiphospholipid syndrome? J Thromb Haemost 2021; 19:1776-1782. [PMID: 33774918 PMCID: PMC8360052 DOI: 10.1111/jth.15320] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Arterial and venous thrombosis are both common in antiphospholipid syndrome (APS). Recent studies have shown that anti-factor Xa (FXa) therapy in APS patients leads to a greater number of patients with arterial thrombosis than with warfarin. We hypothesize that this may be due to the lowering of prothrombin levels by warfarin. OBJECTIVES To investigate whether antiprothrombin antibodies induce platelet aggregation and to identify the platelet receptors involved. A second aim was to investigate the effect of reduced prothrombin levels on antiprothrombin antibody-induced platelet aggregation. METHODS Enzyme-linked immunosorbent assays were performed to measure binding of antiprothrombin antibodies to prothrombin fragment 1+2 and prothrombin. Platelet aggregation assays in washed platelets were performed. FcγRIIA was immunoprecipitated and tyrosine-phosphorylated FcγRIIA was measured by western blot. RESULTS The antiprothrombin antibodies 28F4 and 3B1 had lupus anticoagulant (LAC) activity and caused platelet aggregation in the presence of Ca2+ and prothrombin. Antiprothrombin antibodies without LAC activity did not activate platelets. Inhibition of Syk and Src kinases and FcγRIIA blocked platelet aggregation. Fab and F(ab')2 fragments of 28F4 were unable to induce platelet aggregation. Immunoprecipitations showed that whole 28F4 immunoglobulin G induced tyrosine phosphorylation of FcγRIIA. Platelet aggregation was significantly reduced when prothrombin levels were reduced from 1 µM to 0.2 µM. CONCLUSIONS Antiprothrombin antibodies with LAC activity are able to activate platelets via FcγRIIA. Decreased prothrombin levels resulted in less antiprothrombin antibody-mediated platelet aggregation. This may explain the lower incidence of arterial thrombosis in patients treated with warfarin than with anti-FXa therapy.
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Affiliation(s)
- Walid Chayoua
- Cardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtThe Netherlands
- Synapse Research InstituteMaastrichtThe Netherlands
| | - Phillip L. R. Nicolson
- Institute of Cardiovascular SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
| | - Joost C. M. Meijers
- Department of Molecular and Cellular HemostasisSanquin ResearchAmsterdamThe Netherlands
- Department of Experimental Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Caroline Kardeby
- Institute of Cardiovascular SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
| | - Lourdes Garcia‐Quintanilla
- Institute of Cardiovascular SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
| | - Katrien M. J. Devreese
- Coagulation LaboratoryDepartment of Laboratory MedicineGhent University HospitalGhentBelgium
- Department of Diagnostic SciencesGhent UniversityGhentBelgium
| | - Bas de Laat
- Cardiovascular Research Institute MaastrichtMaastricht University Medical CentreMaastrichtThe Netherlands
- Synapse Research InstituteMaastrichtThe Netherlands
| | - Stephen P. Watson
- Institute of Cardiovascular SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
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Zhu Q, Yang S, Zeng W, Li M, Guan Z, Zhou L, Wang H, Liu Y, Gao Y, Qiu S, Chen C, Li H, Zheng S, Yuan Y, Zhang H, Pan X. A Real-World Observation of Eltrombopag and Recombinant Human Thrombopoietin (rhTPO) in Lymphoma Patients With Chemotherapy Induced Thrombocytopenia. Front Oncol 2021; 11:701539. [PMID: 34490101 PMCID: PMC8418194 DOI: 10.3389/fonc.2021.701539] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Abstract
This real-world, observational study aimed to assess and compare the clinical efficacy and safety of eltrombopag with recombinant human thrombopoietin (rhTPO) in the treatment of chemotherapy induced thrombocytopenia (CIT) in patients with lymphoma. One hundred and fifty-three patients who experienced grade 3 or 4 thrombocytopenia after chemotherapy for lymphoma were enrolled, 51 of which were treated with eltrombopag, 50 with rhTPO, and 52 patients with no drug treatment were served as the control group. The lowest platelet level and mean platelet counts at Day 5, Day 7, and Day 10 were significantly higher in both the eltrombopag group (P=.041,.003,.000,.000) and rhTPO group (P=.005,.005,.000,.000) than the control, but there was no difference between treatment with eltrombopag and rhTPO. Similarly, days required for the recovery of platelet counts to ≥50×109/L and ≥75×109/L were not different between the two treatment groups but significantly higher than the control group (P <.05). Rates of bleeding and platelet transfusion were all significantly reduced in patients treated with eltrombopag (P=.031,.032) or rhTPO (P=.017,.009) when compared to the control. Treatment-related adverse events (AEs) were reported in 7 (13.7%) and 6 (12.0%) patients in the eltrombopag and rhTPO groups, respectively, all being mild and transient in nature. In conclusion, both eltrombopag and rhTPO were effective and safe in the treatment of thrombocytopenia after chemotherapy for lymphoma.
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9
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Magnani HN. Rationale for the Role of Heparin and Related GAG Antithrombotics in COVID-19 Infection. Clin Appl Thromb Hemost 2021; 27:1076029620977702. [PMID: 33539214 PMCID: PMC7868468 DOI: 10.1177/1076029620977702] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/23/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023] Open
Abstract
The SARS-CoV-2 pandemic has focused attention on prevention, restriction and treatment methods that are acceptable worldwide. This means that they should be simple and inexpensive. This review examines the possible role of glycosaminoglycan (GAG) antithrombotics in the treatment of COVID-19. The pathophysiology of this disease reveals a complex interplay between the hemostatic and immune systems that can be readily disrupted by SARS-CoV-2. Some of the GAG antithrombotics also possess immune-modulatory actions and since they are relatively inexpensive they could play an important role in the management of COVID-19 and its complications.
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10
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Martinez-Lopez A, Cuenca-Barrales C, Montero-Vilchez T, Molina-Leyva A, Arias-Santiago S. Review of adverse cutaneous reactions of pharmacologic interventions for COVID-19: A guide for the dermatologist. J Am Acad Dermatol 2020; 83:1738-1748. [PMID: 32777318 PMCID: PMC7413159 DOI: 10.1016/j.jaad.2020.08.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/27/2020] [Accepted: 08/01/2020] [Indexed: 12/15/2022]
Abstract
The new coronavirus, severe acute respiratory syndrome coronavirus 2, is associated with a wide variety of cutaneous manifestations. Although new skin manifestations caused by COVID-19 are continuously being described, other cutaneous entities should also be considered in the differential diagnosis, including adverse cutaneous reactions to drugs used in the treatment of COVID-19 infections. The aim of this review is to provide dermatologists with an overview of the cutaneous adverse effects associated with the most frequently prescribed drugs in patients with COVID-19. The skin reactions of antimalarials (chloroquine and hydroxychloroquine), antivirals (lopinavir/ritonavir, ribavirin with or without interferon, oseltamivir, remdesivir, favipiravir, and darunavir), and treatments for complications (imatinib, tocilizumab, anakinra, immunoglobulins, corticosteroids, colchicine and low molecular weight heparins) are analyzed. Information regarding possible skin reactions, their frequency, management, and key points for differential diagnosis are presented.
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Affiliation(s)
- Antonio Martinez-Lopez
- Dermatology Unit, Virgen de las Nieves University Hospital, Granada, Spain,TECe19–Clinical and Translational Dermatology Investigation Group, Instituto Biosanitario, Granada, Spain
| | - Carlos Cuenca-Barrales
- TECe19–Clinical and Translational Dermatology Investigation Group, Instituto Biosanitario, Granada, Spain
| | | | - Alejandro Molina-Leyva
- Dermatology Unit, Virgen de las Nieves University Hospital, Granada, Spain; TECe19-Clinical and Translational Dermatology Investigation Group, Instituto Biosanitario, Granada, Spain.
| | - Salvador Arias-Santiago
- Dermatology Unit, Virgen de las Nieves University Hospital, Granada, Spain,TECe19–Clinical and Translational Dermatology Investigation Group, Instituto Biosanitario, Granada, Spain,Dermatology Department, University of Granada, Granada, Spain
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11
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Platelet Dysfunction Diseases and Conditions: Clinical Implications and Considerations. Adv Ther 2020; 37:3707-3722. [PMID: 32729008 DOI: 10.1007/s12325-020-01453-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Platelet diseases and dysfunction are taught early in medical school to all future physicians. Understanding of the coagulation cascade and hemostatic mechanisms has allowed for targeted pharmacological therapies that have been significantly impactful in clinical practice. Platelets are an early participant in hemostasis physiologically and under pathophysiological states. METHODS A review of literature involving platelet disfunction. RESULTS Various presentations of platelet diseases and dysfunction challenge clinicians and require a firm understanding of normal platelet function, drugs that mediate or modulate platelet effectiveness, and nonpharmacologic etiologies of platelet diseases and dysfunction with corresponding best practice treatment approaches. CONCLUSION This review summarizes normal and abnormal states associated with platelets and treatment strategies.
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Wolff M, Handtke S, Palankar R, Wesche J, Kohler TP, Kohler C, Gruel Y, Hammerschmidt S, Greinacher A. Activated platelets kill Staphylococcus aureus, but not Streptococcus pneumoniae-The role of FcγRIIa and platelet factor 4/heparinantibodies. J Thromb Haemost 2020; 18:1459-1468. [PMID: 32237268 DOI: 10.1111/jth.14814] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Heparin induced thrombocytopenia (HIT) is likely a misdirected bacterial host defense mechanism. Platelet factor 4 (PF4) binds to polyanions on bacterial surfaces exposing neo-epitopes to which HIT antibodies bind. Platelets are activated by the resulting immune complexes via FcγRIIA, release bactericidal substances, and kill Gram-negative Escherichia coli. OBJECTIVES To assess the role of PF4, anti-PF4/H antibodies and FcγRIIa in killing of Gram-positive bacteria by platelets. METHODS Binding of PF4 to protein-A deficient Staphylococcus aureus (SA113Δspa) and non-encapsulated Streptococcus pneumoniae (D39Δcps) and its conformational change were assessed by flow cytometry using monoclonal (KKO,5B9) and patient derived anti-PF4/H antibodies. Killing of bacteria was quantified by counting colony forming units (cfu) after incubation with platelets or platelet releasate. Using flow cytometry, platelet activation (CD62P-expression, PAC-1 binding) and phosphatidylserine (PS)-exposure were analyzed. RESULTS Monoclonal and patient-derived anti-PF4/H antibodies bound in the presence of PF4 to both S. aureus and S. pneumoniae (1.6-fold increased fluorescence signal for human anti-PF4/H antibodies to 24.0-fold increase for KKO). Staphylococcus aureus (5.5 × 104 cfu/mL) was efficiently killed by platelets (2.7 × 104 cfu/mL) or their releasate (2.9 × 104 cfu/mL). Killing was not further enhanced by PF4 or anti-PF4/H antibodies. Blocking FcγRIIa had no impact on killing of S. aureus by platelets. In contrast, S. pneumoniae was not killed by platelets or releasate. Instead, after incubation with pneumococci platelets were unresponsive to TRAP-6 stimulation and exposed high levels of PS. CONCLUSIONS Anti-PF4/H antibodies seem to have only a minor role for direct killing of Gram-positive bacteria by platelets. Staphylococcus aureus is killed by platelets or platelet releasate. In contrast, S. pneumoniae affects platelet viability.
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Affiliation(s)
- Martina Wolff
- Institut für Immunologie und Transfusion Medizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Stefan Handtke
- Institut für Immunologie und Transfusion Medizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Raghavendra Palankar
- Institut für Immunologie und Transfusion Medizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Jan Wesche
- Institut für Immunologie und Transfusion Medizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Thomas P Kohler
- Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, University of Greifswald, Greifswald, Germany
| | - Christian Kohler
- Institute of Medical Microbiology, University Medicine Greifswald, Greifswald, Germany
| | - Yves Gruel
- Département d'Hématologie-Hémostase, Hôpital Universitaire de Tours, Tours, France
| | - Sven Hammerschmidt
- Department of Molecular Genetics and Infection Biology, Interfaculty Institute for Genetics and Functional Genomics, Center for Functional Genomics of Microbes, University of Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Immunologie und Transfusion Medizin, Universitätsmedizin Greifswald, Greifswald, Germany
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13
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Zhou P, Yin JX, Tao HL, Zhang HW. Pathogenesis and management of heparin-induced thrombocytopenia and thrombosis. Clin Chim Acta 2020; 504:73-80. [DOI: 10.1016/j.cca.2020.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 01/19/2023]
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14
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Dulicek P, Ivanova E, Kostal M, Fiedlerova Z, Sadilek P, Hirmerova J. Heparin-induced thrombocytopenia treated with fondaparinux: single center experience. INT ANGIOL 2019; 39:76-81. [PMID: 31782283 DOI: 10.23736/s0392-9590.19.04247-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is the most frequent drug-induced, immune-mediated thrombocytopenia. It is associated with significant morbidity and mortality. Anticoagulation with heparin must be stopped immediately and replaced by some suggested alternative - lepirudin, danaparoid or argatroban. Fondaparinux has been also successfully used in HIT. METHODS We present a cohort of 10 patients diagnosed with HIT and treated in a university hospital in a period of four years. Diagnosis was based on Keeling´s scoring system, screening immunologic test for HIT (STic EXPERT® HIT) and sandwich ELISA (detection of IgG/heparin-PF4 antibodies). While other alternative anticoagulants are not readily available in our hospital, we used fondaparinux in all cases. RESULTS From 2014 to 2018, eight males and two females (mean age 67 years, range 46-86 years) were diagnosed with HIT in our hospital. This complication developed in 9 cases after low-molecular-weight heparin and in one after heparin flushes in hemodialysis. A drop-in platelet count developed in all patients, thrombotic complications in 7 and skin necrosis in 2 cases. Fondaparinux was used in all patients, including two cases with severe renal impairment, the dose was chosen individually. We observed complete platelet recovery in all cases. One patient died because of advanced malignancy, others did not have any complication. In 6 cases we switched to oral anticoagulation after platelet recovery. CONCLUSIONS In our group of 10 HIT patients fondaparinux was shown to be both safe and effective, even in those with severe renal impairment. Additional studies are warranted to confirm this observation.
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Affiliation(s)
- Petr Dulicek
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Eva Ivanova
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Milan Kostal
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Zuzana Fiedlerova
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Petr Sadilek
- Fourth Department of Internal Medicine and Hematology, Faculty of Medicine, University Hospital of Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jana Hirmerova
- Second Department of Internal Medicine, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic - .,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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15
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Management of Cerebral Venous Thrombosis in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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16
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Iba T, Watanabe E, Umemura Y, Wada T, Hayashida K, Kushimoto S, Wada H. Sepsis-associated disseminated intravascular coagulation and its differential diagnoses. J Intensive Care 2019; 7:32. [PMID: 31139417 PMCID: PMC6528221 DOI: 10.1186/s40560-019-0387-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/02/2019] [Indexed: 12/19/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is a common complication in sepsis. Since DIC not only promotes organ dysfunction but also is a strong prognostic factor, its diagnosis at the earliest possible timing is important. Thrombocytopenia is often present in patients with DIC but can also occur in a number of other critical conditions. Of note, many of the rare thrombocytopenic diseases require prompt diagnoses and specific treatments. To differentiate these diseases correctly, the phenotypic expressions must be considered and the different disease pathophysiologies must be understood. There are three major players in the background characteristics of thrombocytopenia: platelets, the coagulation system, and vascular endothelial cells. For example, the activation of coagulation is at the core of the pathogenesis of sepsis-associated DIC, while platelet aggregation is the essential mechanism in thrombotic thrombocytopenic purpura and endothelial damage is the hallmark of hemolytic uremic syndrome. Though each of the three players is important in all thrombocytopenic diseases, one of the three dominant players typically establishes the individual features of each disease. In this review, we introduce the pathogeneses, symptoms, diagnostic measures, and recent therapeutic advances for the major diseases that should be immediately differentiated from DIC in sepsis.
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Affiliation(s)
- Toshiaki Iba
- 1Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Eizo Watanabe
- 2Department of General Medical Science Graduate School of Medicine Chiba University, Chiba, Japan.,Department of Emergency and Critical Care Medicine Eastern Chiba Medical Center, Chiba, Japan
| | - Yutaka Umemura
- 4Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeshi Wada
- 5Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kei Hayashida
- 6Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Shigeki Kushimoto
- 7Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Hideo Wada
- 8Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Japan
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17
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Kuitunen A, Sinisalo M, Vahtera A, Hiltunen L, Javela K, Laine O. Autoimmune heparin-induced thrombocytopenia of delayed onset: a clinical challenge. Transfusion 2018; 58:2757-2760. [PMID: 30284726 DOI: 10.1111/trf.14814] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 05/07/2018] [Accepted: 05/16/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) usually appears at 5 to 10 days after initiation of heparin. Autoimmune HIT can arise after discontinuation of heparin treatment (delayed-onset HIT) or without any preceding heparin exposure (spontaneous HIT syndrome). CASE REPORT This case presents a course of autoimmune HIT with delayed onset. The patient was hospitalized due to influenza pneumonia and received low-molecular-weight heparin thromboprophylaxis for 9 days. Seven days after discharge, she was readmitted because of a cerebral sinus vein thrombosis and severe thrombocytopenia. Intracranial bleeding and brain infarction caused her death. DISCUSSION Autoimmune HIT was confirmed by functional heparin-induced platelet (PLT) activation test. Intracranial bleeding prevented continuous and effective anticoagulation. PLT transfusions were given, although they are generally advised against in HIT patients due to potential risk of thromboembolic events. CONCLUSION This case presents that testing PLT-activating antibodies both in the presence and in the absence of current heparin treatment helps to diagnose patients with autoimmune HIT. There is conflicting evidence to refuse PLT transfusion when HIT is complicated with life-threatening bleeding.
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Affiliation(s)
- Anne Kuitunen
- Department of Intensive Care, Tampere University Hospital, Tampere, Finland
| | - Marjatta Sinisalo
- the Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Annukka Vahtera
- Department of Intensive Care, Tampere University Hospital, Tampere, Finland
| | | | - Kaija Javela
- the Finnish Red Cross Blood Service, Helsinki, Finland
| | - Outi Laine
- the Department of Internal Medicine, Tampere University Hospital, Tampere, Finland.,the Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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18
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Wahby KA, Riley LK, Tennenberg SD. Assessment of an Extended Interval Fondaparinux Dosing Regimen for Venous Thromboembolism Prophylaxis in Critically Ill Patients with Severe Renal Dysfunction Using Antifactor Xa Levels. Pharmacotherapy 2018; 37:1241-1248. [PMID: 28833353 DOI: 10.1002/phar.2014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Pharmacologic options for venous thromboembolism (VTE) prophylaxis are often limited in critically ill patients due to thrombocytopenia and multisystem organ dysfunction. Fondaparinux offers potential advantages in the critically ill; however, it is currently contraindicated in severe renal dysfunction (SRD). We evaluated anti-factor Xa levels in critically ill patients with SRD who were receiving an extended interval dosing regimen of fondaparinux for VTE prophylaxis. METHODS A prospective, single-arm, interventional study was conducted at two academic hospitals of the Detroit Medical Center. Eligible patients were in the intensive care unit, had an estimated creatinine clearance of less than 30 ml/minute, and had either acute kidney injury or end-stage renal disease; several patients were taking renal replacement therapy. Fondaparinux was administered at an extended interval dosing regimen of 2.5 mg subcutaneously every 48 hours. Fondaparinux peak and trough anti-factor Xa levels were obtained. Lower extremity venous duplex studies were performed at baseline and study completion to assess for deep vein thrombosis (DVT), and patients were monitored for bleeding complications. RESULTS Thirty-two patients were enrolled. Patients received a median of four doses (interquartile range two to five) of fondaparinux. Fondaparinux peak (n=98) and trough (n=86) anti-factor Xa levels were 0.36 ± 0.18 mg/L and 0.17 ± 0.11 mg/L (mean ± SD), respectively, and were similar to levels reported in patients with normal renal function receiving conventional once-daily dosing. No lower extremity DVTs or suspected VTE events occurred. Two (6%) patients had significant bleeding events. CONCLUSIONS In critically ill patients with SRD, an extended interval fondaparinux dosing regimen of 2.5 mg every 48 hours for VTE prophylaxis achieved peak and trough anti-factor Xa levels similar to those reported in noncritically ill patients with normal renal function receiving once-daily fondaparinux. This regimen offers an alternative for patients with SRD when heparinoids must be avoided.
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Affiliation(s)
- Krista A Wahby
- Department of Pharmacy, Harper University Hospital, Detroit, Michigan
| | - Lauren K Riley
- Department of Pharmacy, Detroit Receiving Hospital, Detroit, Michigan
| | - Steven D Tennenberg
- Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan
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19
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Tillman BF, Matafonov A, Kingeter AJ, Shah AS, Gailani D. Effects of Plasma Exchange and Heparin Concentration on the Serotonin Release Assay in Heparin-Induced Thrombocytopenia. ACTA ACUST UNITED AC 2017; 2:380-385. [DOI: 10.1373/jalm.2017.023929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/24/2017] [Indexed: 11/06/2022]
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20
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Ezekwudo DE, Chacko R, Gbadamosi B, Batool S, Gaikazian S, Warkentin TE, Sheppard JAI, Jaiyesimi I. Apixaban for treatment of confirmed heparin-induced thrombocytopenia: a case report and review of literature. Exp Hematol Oncol 2017; 6:21. [PMID: 28725494 PMCID: PMC5513338 DOI: 10.1186/s40164-017-0080-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/05/2017] [Indexed: 02/08/2023] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening condition caused by the binding of platelet-activating antibodies (IgG) to multimolecular platelet factor 4 (PF4)/heparin complexes because of heparin exposure. The by-product of this interaction is thrombin formation which substantially increases the risk of venous and/or arterial thromboembolism. Currently, only one anticoagulant, argatroban, is United States Food and Drug Administration-approved for management of HIT; however, this agent is expensive and can only be given by intravenous infusion. Recently, several retrospective case-series, case reports, and one prospective study suggest that direct oral anticoagulants (DOACs) are also efficacious for treating HIT. We further review the literature regarding current diagnosis and clinical management of HIT. Case presentation A 66-year-old male patient developed HIT beginning on day 5 post-cardiovascular surgery; the platelet count nadir on day 10 measured 16 × 109/L. Both the PF4-dependent ELISA and Serotonin-release assay were strongly positive. Despite initial anticoagulation with argatroban (day 6), the patient developed symptomatic Doppler ultrasound-documented bilateral lower extremity deep vein thrombosis on day 14 post-surgery. The patient was transitioned to the DOAC, apixaban, while still thrombocytopenic (platelet count 108) and discharged to home, with platelet count recovery and no further thrombosis at 3-month follow-up. Conclusions We report a patient with serologically confirmed HIT who developed symptomatic bilateral lower limb deep vein thrombosis despite anticoagulation with argatroban. The patient was switched to oral apixaban and made a complete recovery. Our patient case adds to the emerging literature suggesting that DOAC therapy is safe and efficacious for management of proven HIT.
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Affiliation(s)
- Daniel E Ezekwudo
- Department of Hematology and Oncology, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3577 W. 13 Mile Rd., Suite 202a, Royal Oak, MI USA
| | - Rebecca Chacko
- Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI USA
| | - Bolanle Gbadamosi
- Department of Hematology and Oncology, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3577 W. 13 Mile Rd., Suite 202a, Royal Oak, MI USA
| | - Syeda Batool
- Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI USA
| | - Sussana Gaikazian
- Department of Hematology and Oncology, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3577 W. 13 Mile Rd., Suite 202a, Royal Oak, MI USA
| | - Theodore E Warkentin
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8 Canada.,Department of Pathology & Molecular Medicine, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8 Canada
| | - Jo-Ann I Sheppard
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8 Canada.,Department of Pathology & Molecular Medicine, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8 Canada
| | - Ishmael Jaiyesimi
- Department of Hematology and Oncology, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3577 W. 13 Mile Rd., Suite 202a, Royal Oak, MI USA.,Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI USA
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Doucette K, DeStefano CB, Jain NA, Cruz AL, Malkovska V, Fitzpatrick K. Treatment of refractory delayed onset heparin-induced thrombocytopenia after thoracic endovascular aortic repair with intravenous immunoglobulin (IVIG). Res Pract Thromb Haemost 2017; 1:134-137. [PMID: 30046682 PMCID: PMC6058197 DOI: 10.1002/rth2.12009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 05/05/2017] [Indexed: 02/02/2023] Open
Abstract
Delayed onset heparin induced thrombocytopenia (HIT), is characterized by a late nadir due to persistent platelet-activating IgG antibodies. It typically begins or worsens 5 or more days after heparin is discontinued with complications such as thrombosis up to 3 weeks after exposure to heparin.1-3 In 50% of cases, the platelet count can decrease to very low numbers (<20 000/μL), which is not usual for typical HIT. Here we report 2 cases of post-operative delayed onset HIT manifesting as severe thrombocytopenia that persisted despite cessation of heparin and initiation of argatroban. Key Clinical Question: Is intravenous immunoglulin beneficial in severe refractory delayed-onset HIT?
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Affiliation(s)
- Kimberley Doucette
- Department of Internal MedicineMedstar Washington Hospital CenterWashingtonDCUSA
| | | | - Natasha A. Jain
- Department of Internal MedicineMedstar Washington Hospital CenterWashingtonDCUSA
| | - Allan L. Cruz
- Department of Hematology/OncologyMedstar Washington Hospital CenterWashingtonDCUSA
| | - Vera Malkovska
- Department of Hematology/OncologyMedstar Washington Hospital CenterWashingtonDCUSA
| | - Kelly Fitzpatrick
- Department of Hematology/OncologyMedstar Washington Hospital CenterWashingtonDCUSA
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22
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Abstract
Direct oral anticoagulants (DOACs) are attractive options for treatment of heparin-induced thrombocytopenia (HIT). We report our continuing experience in Hamilton, ON, Canada, since January 1, 2015 (when we completed our prospective study of rivaroxaban for HIT), using rivaroxaban for serologically confirmed HIT (4Ts score ≥4 points; positive platelet factor 4 [PF4]/heparin immunoassay, positive serotonin-release assay). We also performed a literature review of HIT treatment using DOACs (rivaroxaban, apixaban, dabigatran, edoxaban). We focused on patients who received DOAC therapy for acute HIT as either primary therapy (group A) or secondary therapy (group B; initial treatment using a non-DOAC/non-heparin anticoagulant with transition to a DOAC during HIT-associated thrombocytopenia). Our primary end point was occurrence of objectively documented thrombosis during DOAC therapy for acute HIT. We found that recovery without new, progressive, or recurrent thrombosis occurred in all 10 Hamilton patients with acute HIT treated with rivaroxaban. Data from the literature review plus these new data identified a thrombosis rate of 1 of 46 patients (2.2%; 95% CI, 0.4%-11.3%) in patients treated with rivaroxaban during acute HIT (group A, n = 25; group B, n = 21); major hemorrhage was seen in 0 of 46 patients. Similar outcomes in smaller numbers of patients were observed with apixaban (n = 12) and dabigatran (n = 11). DOACs offer simplified management of selected patients, as illustrated by a case of persisting (autoimmune) HIT (>2-month platelet recovery with inversely parallel waning of serum-induced heparin-independent serotonin release) with successful outpatient rivaroxaban management of HIT-associated thrombosis. Evidence supporting efficacy and safety of DOACs for acute HIT is increasing, with the most experience reported for rivaroxaban.
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Padmanabhan A, Jones CG, Pechauer SM, Curtis BR, Bougie DW, Irani MS, Bryant BJ, Alperin JB, Deloughery TG, Mulvey KP, Dhakal B, Wen R, Wang D, Aster RH. IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia. Chest 2017; 152:478-485. [PMID: 28427966 DOI: 10.1016/j.chest.2017.03.050] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) complicated by severe thrombocytopenia and thrombosis can pose significant treatment challenges. Use of alternative anticoagulants in this setting may increase bleeding risks, especially in patients who have a protracted disease course. Additional therapies are lacking in this severely affected patient population. METHODS We describe three patients with HIT who had severe thromboembolism and prolonged thrombocytopenia refractory to standard treatment but who achieved an immediate and sustained response to IVIg therapy. The mechanism of action of IVIg was evaluated in these patients and in five additional patients with severe HIT. The impact of a common polymorphism (H/R 131) in the platelet IgG receptor FcγRIIa on IVIg-mediated inhibition of platelet activation was also examined. RESULTS At levels attained in vivo, IVIg inhibits HIT antibody-mediated platelet activation. The constant domain of IgG (Fc) but not the antigen-binding portion (Fab) is required for this effect. Consistent with this finding, IVIg had no effect on HIT antibody binding in a solid-phase HIT immunoassay (platelet factor 4 enzyme-linked immunoassay). The H/R131 polymorphism in FcγRIIa influences the susceptibility of platelets to IVIg treatment, with the HH131 genotype being most susceptible to IVIg-mediated inhibition of antibody-induced activation. However, at high doses of IVIg, activation of platelets of all FcγRIIa genotypes was significantly inhibited. All three patients did well on long-term anticoagulation therapy with direct oral anticoagulants. CONCLUSIONS These studies suggest that IVIg treatment should be considered in patients with HIT who have severe disease that is refractory to standard therapies.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI.
| | - Curtis G Jones
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | | | - Brian R Curtis
- Platelet and Neutrophil Immunology Laboratory, BloodCenter of Wisconsin, Milwaukee, WI
| | - Daniel W Bougie
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Mehraboon S Irani
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Barbara J Bryant
- Department of Pathology, University of Texas Medical Branch, Galveston, TX
| | - Jack B Alperin
- Department of Pathology, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | | | - Kevin P Mulvey
- Department of Medicine, Kootenai Health, Coeur d'Alene, ID
| | - Binod Dhakal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Renren Wen
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Demin Wang
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Richard H Aster
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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24
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Abstract
Heparin-induced thrombocytopenia (HIT) is an immune complication of heparin therapy caused by antibodies to complexes of platelet factor 4 (PF4) and heparin. Pathogenic antibodies to PF4/heparin bind and activate cellular FcγRIIA on platelets and monocytes to propagate a hypercoagulable state culminating in life-threatening thrombosis. It is now recognized that anti-PF4/heparin antibodies develop commonly after heparin exposure, but only a subset of sensitized patients progress to life-threatening complications of thrombocytopenia and thrombosis. Recent scientific developments have clarified mechanisms underlying PF4/heparin immunogenicity, disease susceptibility, and clinical manifestations of disease. Insights from clinical and laboratory findings have also been recently harnessed for disease prevention. This review will summarize our current understanding of HIT by reviewing pathogenesis, essential clinical and laboratory features, and management.
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Fondaparinux Outpatient Use for Patients with a Heparin-Induced Thrombocytopenia History: A Case Report and Review. PHARMACY 2016; 5:pharmacy5010001. [PMID: 28970413 PMCID: PMC5419381 DOI: 10.3390/pharmacy5010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 12/05/2016] [Accepted: 12/16/2016] [Indexed: 11/17/2022] Open
Abstract
The purpose of this article is to report a case of fondaparinux outpatient utilization for anticoagulation in a patient with a past medical history of heparin-induced thrombocytopenia (HIT) and discuss the options and need for future anticoagulation research in this unique patient population. A 63-year-old Caucasian female with a previous medical history of HIT thromboprophylaxed with warfarin for a pulmonary embolism presented to an anticoagulation clinic with a subtherapeutic international normalized ratio (INR) after missed warfarin doses. The patient was instructed to increase her warfarin dose and was prescribed fondaparinux daily injections until her INR was in range. The patient tolerated the fondaparinux therapy without thromboembolic, thrombocytopenia or bleeding occurrence. Fondaparinux therapy for HIT is controversial and differs between established guidelines. Currently, there is no studied use of fondaparinux for thromboprophylaxis in warfarin therapy outpatients with a HIT history who need thromboprophylaxis while undergoing therapy for a procedure, or those who have a subtherapeutic INR. Further study of the outpatient use of fondaparinux for this patient subset is needed to explore the potential benefit of an outpatient, less invasive, less expensive and potentially better tolerated option.
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Cost-effectiveness of anticoagulants for suspected heparin-induced thrombocytopenia in the United States. Blood 2016; 128:3043-3051. [PMID: 27793877 PMCID: PMC6863170 DOI: 10.1182/blood-2016-07-728030] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/11/2016] [Indexed: 12/19/2022] Open
Abstract
Despite the availability of multiple nonheparin anticoagulants for the treatment of heparin-induced thrombocytopenia (HIT), few data are available comparing the cost-effectiveness of these agents. This analysis is particularly important when considering differences in the risk of adverse effects, routes of administration, requirements for phlebotomy and laboratory monitoring, and overall drug costs. We conducted a cost-effectiveness analysis of argatroban, bivalirudin, and fondaparinux for the treatment of suspected HIT from the institutional perspective. A 3-arm decision-tree model was developed that employs standard practices for anticoagulation monitoring. We incorporated published data on drug efficacy and probability of HIT-related thromboembolism and major bleeding. We considered both institutional costs and average wholesale price (AWP) and performed probabilistic sensitivity analyses (PSA) to address any uncertainty in model parameters. Using institutional costs, fondaparinux prevailed over both argatroban and bivalirudin in terms of cost ($151 vs $1250 and $1466, respectively) and adverse events averted (0.9989 vs 0.9957 and 0.9947, respectively). Results were consistent when AWP was used, with fondaparinux being less expensive ($555 vs $3081 and $2187, respectively) and more effective in terms of adverse events averted (0.9989 vs 0.9957 and 0.9947, respectively). The PSA confirmed our findings using both institutional costs and AWP. In conclusion, fondaparinux subcutaneous injection afforded significant advantages in terms of cost savings and adverse events averted compared with IV argatroban or bivalirudin infusions. Our data strongly suggest potential cost savings with fondaparinux and underscore the critical need for larger clinical studies of fondaparinux in the treatment of suspected HIT.
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Warkentin TE. Acute intraoperative HIT during heart surgery: Why so rare? Thromb Res 2016; 146:110-112. [DOI: 10.1016/j.thromres.2016.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/10/2016] [Indexed: 11/26/2022]
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Warkentin TE. Clinical picture of heparin-induced thrombocytopenia (HIT) and its differentiation from non-HIT thrombocytopenia. Thromb Haemost 2016; 116:813-822. [PMID: 27656712 DOI: 10.1160/th16-06-0435] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/12/2016] [Indexed: 12/14/2022]
Abstract
HIT is an acquired antibody-mediated disorder strongly associated with thrombosis, including microthrombosis secondary to disseminated intravascular dissemination (DIC). The clinical features of HIT are reviewed from the perspective of the 4Ts scoring system for HIT, which emphasises its characteristic timing of onset of thrombocytopenia. HIT antibodies recognize multimolecular complexes of platelet factor 4 (PF4)/heparin. However, a subset of HIT sera recognise PF4 bound to platelet chondroitin sulfate; these antibodies activate platelets in vitro and in vivo even in the absence of heparin, thus explaining: delayed-onset HIT (where HIT begins or worsens after stopping heparin); persisting HIT (where HIT takes several weeks to recover); spontaneous HIT syndrome (a disorder clinically and serologically resembling HIT but without proximate heparin exposure); and fondaparinux-associated HIT (four distinct syndromes featuring thrombocytopenia that begins or worsens during treatment with fondaparinux), with a new patient case presented with ongoing thrombocytopenia (and fatal haemorrhage) during treatment of HIT with fondaparinux, with fondaparinux-dependent platelet activation induced by patient serum ("fondaparinux cross-reactivity"). Ironically, despite existence of fondaparinux-associated HIT, this pentasaccharide anticoagulant is a frequent treatment for HIT (including one used by the author). HIT can be confused with other disorders, including those with a) timing similar to HIT (e. g. abciximab-associated thrombocytopenia of delayed-onset); b) combined thrombocytopenia/thrombosis (e. g. symmetrical peripheral gangrene secondary to acute DIC and shock liver); and c) both timing of onset and thrombosis (e. g. warfarin-associated venous limb gangrene complicating cancer-associated DIC). By understanding clinical and pathophysiological similarities and differences between HIT and non-HIT mimicking disorders, the clinician is better able to make the correct diagnosis.
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Affiliation(s)
- Theodore E Warkentin
- Prof. Theodore (Ted) E. Warkentin, Hamilton Regional Laboratory Medicine Program, Room 1-270B, Hamilton General Hospital, 237 Barton St. E., Hamilton, Ontario L8L 2X2, Canada, Tel.: +1 905 527 0271 ext. 46139, Fax: +1 905 577 1421, E-mail:
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