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Kamata M, Sebastian R, McConnell PI, Gomez D, Naguib A, Tobias JD. Perioperative care in an adolescent patient with heparin-induced thrombocytopenia for placement of a cardiac assist device and heart transplantation: case report and literature review. Int Med Case Rep J 2017; 10:55-63. [PMID: 28243155 PMCID: PMC5317301 DOI: 10.2147/imcrj.s118250] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) can cause life-threatening complications following the administration of heparin. Discontinuation of all sources of heparin exposure and the use of alternative agents for anticoagulation are necessary when HIT is suspected or diagnosed. We present the successful use of bivalirudin anticoagulation in an adolescent patient during cardiopulmonary bypass who underwent both placement of a left ventricular assist device and subsequent heart transplantation within a 36-hour period. The pathophysiology and diagnosis of HIT are reviewed, previous reports of the use of direct thrombin inhibitors for cardiac surgery are presented, and potential dosing regimens for bivalirudin are discussed.
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Affiliation(s)
- Mineto Kamata
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital
| | - Roby Sebastian
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine
| | | | - Daniel Gomez
- Cardiovascular Perfusion Services and Heart Center, Nationwide Children's Hospital and The Ohio State University
| | - Aymen Naguib
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Latham GJ, Jefferis Kirk C, Falconer A, Dickey R, Albers EL, McMullan DM. Challenging Argatroban Management of a Child on Extracorporeal Support and Subsequent Heart Transplant. Semin Cardiothorac Vasc Anesth 2015; 20:168-74. [DOI: 10.1177/1089253215624766] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
A 6-year-old child developed heparin-induced thrombocytopenia while on extracorporeal life support. Hours after a difficult transition from heparin to argatroban for anticoagulation therapy, the child underwent heart transplantation. Intraoperative management was plagued with circuit thrombus formation while on cardiopulmonary bypass and subsequent massive hemorrhage after bypass. We review the child’s anticoagulation management, clinical challenges encountered, and review current literature related to the use of argatroban in pediatric cardiac surgery.
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Affiliation(s)
- Gregory J. Latham
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | | | | | | | - Erin L. Albers
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - David Michael McMullan
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
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3
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Moffett BS, Teruya J. Trends in Parenteral Direct Thrombin Inhibitor Use in Pediatric Patients: Analysis of a Large Administrative Database. Arch Pathol Lab Med 2014; 138:1229-32. [DOI: 10.5858/arpa.2013-0436-oa] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Parenteral direct thrombin inhibitors (DTIs) may be used in pediatric patients with contraindications to heparin therapy, such as heparin-induced thrombocytopenia. Few data exist regarding the use of DTIs in pediatric patients.
Objective.—To characterize the use of DTIs in pediatric patients, including monitoring strategies and bleeding complications.
Design.—A retrospective descriptive study was designed and the Pediatric Health Information System database was queried from 2004 to 2011 for pediatric patients receiving a parenteral DTI. Patient demographic and hospital data, mortality, disease state, and procedure information (from International Classification of Diseases, Ninth Revision codes) were collected from the query. DTI monitoring information was also collected. Patients were divided into 2 time periods (2004–2007, 2008–2011) to evaluate trends.
Results.—Two hundred eight patients met study criteria (50.9% male, 64.4% white), and children (2–12 years of age) represented 34.6% of the population. Congenital heart disease was present in 43.8% and cardiovascular surgical procedure occurred in 28.4%. Argatroban was most commonly used (73.1%) and bivalirudin use increased (P < .001). Bleeding complications were present in 37.9% of patients and mortality was 19.7%. Bleeding complications were associated with lepirudin (62.5%) and argatroban (41.7%) more often as compared with bivalirudin (18.8%) (P < .001). Activated partial thromboplastin time and prothrombin time were used more often in patients receiving argatroban and lepirudin in comparison with bivalirudin, and thrombin time was used more often in patients receiving lepirudin (P < .001). Activated clotting time use increased over time (5.1% versus 17.5%, P = .02).
Conclusion.—Pediatric use of DTIs is infrequent and occurs in patients with high morbidity and mortality.
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Affiliation(s)
- Brady S. Moffett
- From the Department of Pharmacy, Texas Children's Hospital, and the Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine, Houston (Dr Moffett); and the Department of Pathology & Immunology, Pediatrics, and Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston (Dr Teruya)
| | - Jun Teruya
- From the Department of Pharmacy, Texas Children's Hospital, and the Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine, Houston (Dr Moffett); and the Department of Pathology & Immunology, Pediatrics, and Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston (Dr Teruya)
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4
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, Feltes TF, Foster E, Hinoki K, Ichord RN, Kreutzer J, McCrindle BW, Newburger JW, Tabbutt S, Todd JL, Webb CL. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation 2013; 128:2622-703. [DOI: 10.1161/01.cir.0000436140.77832.7a] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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5
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Delayed-type heparin allergy: diagnostic procedures and treatment alternatives-a case series including 15 patients. World Allergy Organ J 2013; 1:194-9. [PMID: 23282847 PMCID: PMC3650972 DOI: 10.1097/wox.0b013e31818def58] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Delayed-type hypersensitivity reactions (DTHRs) after subcutaneous application of unfractionated heparins or low-molecular-weight heparins are not uncommon. Standard allergological testing usually includes intracutaneous skin tests and patch testing of different heparins, heparinoids, and thrombin inhibitors followed by subcutaneous and/or intravenous challenge with skin test-negative drugs. We present data from a single-center case series of 15 patients with DTHR after low-molecular-weight heparin administration. Intracutaneous testing that can be considered as gold standard identified the suspicious elicitor in 11 (73.4%) of 15 of the patients. Patch testing was positive in 5 (33.4%) of 15 of the patients and was only positive in patients who were also reacting in the intradermal testing. Intravenous challenge with heparin sodium was performed in 10 of 15 patients and was well tolerated in all cases, despite prior positive intracutaneous tests with the same substance. Intracutaneous documentation of DTHR was not an adequate predictor of intravenous challenge.
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6
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Agarwal S, Ullom B, Al-Baghdadi Y, Okumura M. Challenges encountered with argatroban anticoagulation during cardiopulmonary bypass. J Anaesthesiol Clin Pharmacol 2012; 28:106-10. [PMID: 22345956 PMCID: PMC3275940 DOI: 10.4103/0970-9185.92458] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Use of argatroban as an alternative to heparin during cardiopulmonary bypass (CPB) in patients with heparin-induced thrombocytopenia has gained some attention in the past two decades. Dosing of argatroban during CPB is complex due to lack of complete understanding of its pharmacokinetic profile and the various elements during CPB that may alter its plasma levels. We report a case where the challenges in dosing argatroban led to failure to provide adequate anticoagulation during CPB, as evidenced by clot formation in the oxygenator, and extensive bleeding in the postoperative period.
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Affiliation(s)
- Shvetank Agarwal
- Department of Anesthesiology, Wayne State University/Detroit Medical Center, Detroit, MI, USA
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7
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Lancaster C, Tobias JD. Why Is the Platelet Count Low: Should I Be Concerned About Heparin-Induced Thrombocytopenia? J Pediatr Pharmacol Ther 2012; 17:2-6. [DOI: 10.5863/1551-6776-17.1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Christopher Lancaster
- Departments of Anesthesiology and Pediatrics, Nationwide Children's Hospital, and the Ohio State University, Columbus, Ohio
| | - Joseph D Tobias
- Departments of Anesthesiology and Pediatrics, Nationwide Children's Hospital, and the Ohio State University, Columbus, Ohio
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Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S-e801S. [PMID: 22315277 DOI: 10.1378/chest.11-2308] [Citation(s) in RCA: 958] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. METHODS The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). CONCLUSIONS The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
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Affiliation(s)
- Paul Monagle
- Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO
| | - Rebecca N Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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9
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Jeske WP, Fareed J, Hoppensteadt DA, Lewis B, Walenga JM. Pharmacology of argatroban. Expert Rev Hematol 2011; 3:527-39. [PMID: 21083469 DOI: 10.1586/ehm.10.53] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Argatroban is a synthetic, small-molecule direct thrombin inhibitor that is approved in the USA, the EU and Japan for prophylaxis or treatment of thrombosis in patients with heparin-induced thrombocytopenia (HIT), and for anticoagulation of HIT patients undergoing PCI. Argatroban binds reversibly to, and inhibits both soluble and clot-bound thrombin. Argatroban does not generate antibodies, is not susceptible to degradation by proteases and is cleared hepatically. It has a predictable anticoagulant effect and there is a good correlation between dose, plasma concentration and pharmacodynamic effect. Initial clinical studies suggest that further investigations to establish the use of argatroban in ischemic stroke, acute coronary syndrome, hemodialysis, blood oxygenation, off-pump cardiac surgery and other clinical indications are warranted.
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Affiliation(s)
- Walter P Jeske
- Cardiovascular Institute, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA.
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10
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Schaden E, Kozek-Langenecker SA. Direct thrombin inhibitors: pharmacology and application in intensive care medicine. Intensive Care Med 2010; 36:1127-37. [PMID: 20425104 DOI: 10.1007/s00134-010-1888-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 03/24/2010] [Indexed: 01/31/2023]
Abstract
PURPOSE Anticoagulation is part of the daily routine of intensive care physicians. As the possibilities of pharmacological anticoagulation are becoming more numerous and diverse, intensive care physicians have to be familiar with indications, contraindications, dosing, and reversal of many different substances. This paper presents an overview of the substance group of direct thrombin inhibitors (DTI) indicated for alternative anticoagulation in intensive care medicine. METHODS The review is a synopsis of scientific evidence, expert opinion, open forum commentary, and clinical feasibility data. RESULTS AND CONCLUSIONS Due to their antithrombotic potential without direct activation of platelets, DTI could offer potential advantages over heparins and vitamin K antagonists in critically ill patients, especially regarding heparin-induced thrombocytopenia. Because of multiple organ dysfunction, organ failure, and comedications, simple extrapolation of results of medical to critically ill patients is not permissible. The fine line between thrombosis and bleeding in intensive care patients requires cautious dosing and close drug monitoring. Studies dealing with DTI in the intensive care setting are of utmost clinical interest.
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Affiliation(s)
- Eva Schaden
- Department of Anesthesiology, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Guertel 18-20, 1090, Vienna, Austria.
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11
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Follis F, Filippone G, Montalbano G, Floriano M, LoBianco E, D'Ancona G, Follis M. Argatroban as a substitute of heparin during cardiopulmonary bypass: a safe alternative? Interact Cardiovasc Thorac Surg 2010; 10:592-6. [DOI: 10.1510/icvts.2009.215848] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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13
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Genzen JR, Fareed J, Hoppensteadt D, Kurup V, Barash P, Coady M, Wu YY. Prolonged elevation of plasma argatroban in a cardiac transplant patient with a suspected history of heparin-induced thrombocytopenia with thrombosis. Transfusion 2009; 50:801-7. [PMID: 20003049 DOI: 10.1111/j.1537-2995.2009.02531.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Direct thrombin inhibitors (DTIs) provide an alternative method of anticoagulation for patients with a history of heparin-induced thrombocytopenia (HIT) or HIT with thrombosis (HITT) undergoing cardiopulmonary bypass (CPB). In the following report, a 65-year-old critically ill patient with a suspected history of HITT was administered argatroban for anticoagulation on bypass during heart transplantation. The patient required massive transfusion support (55 units of red blood cells, 42 units of fresh-frozen plasma, 40 units of cryoprecipitate, 40 units of platelets, and three doses of recombinant Factor VIIa) for severe intraoperative and postoperative bleeding. STUDY DESIGN AND METHODS Plasma samples from before and after CPB were analyzed postoperatively for argatroban concentration using a modified ecarin clotting time (ECT) assay. RESULTS Unexpectedly high concentrations of argatroban were measured in these samples (range, 0-32 microg/mL), and a prolonged plasma argatroban half life (t(1/2)) of 514 minutes was observed (published elimination t(1/2) is 39-51 minutes [< or = 181 minutes with hepatic impairment]). CONCLUSIONS Correlation of plasma argatroban concentration versus the patient's coagulation variables and clinical course suggest that prolonged elevated levels of plasma argatroban may have contributed to the patient's extended coagulopathy. Because DTIs do not have reversal agents, surgical teams and transfusion services should remain aware of the possibility of massive transfusion events during anticoagulation with these agents. This is the first report to measure plasma argatroban concentration in the context of CPB and extended coagulopathy.
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Affiliation(s)
- Jonathan R Genzen
- Department of Laboratory Medicine, Cardiothoracic, Yale University School of Medicine, New Haven, CT, USA.
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14
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[Direct thrombin inhibitors: pharmacology and application in cardiovascular anesthesia]. Anaesthesist 2009; 57:597-606. [PMID: 18311550 DOI: 10.1007/s00101-008-1347-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The options for drug-controlled anticoagulation are becoming noticeably more manifold. In the area of anaesthesiology and intensive care, there are furthermore special disease patterns, such as heparin-induced thrombocytopenia (HIT) to be known, diagnosed and treated. This article gives a review of the substance groups of the direct thrombin inhibitors (DTI) as alternative anticoagulants for HIT in combination with cardiovascular diseases. For the administration of DTIs, experience and the correct dose are the keys to success and are the deciding factors for the two sides of haemostasis: thrombosis and haemorrhage.
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15
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Kleinschmidt S, Stephan B, Pindur G, Bauer C. [Argatroban: pharmacological properties and anaesthesiological aspects]. Anaesthesist 2009; 55:443-50. [PMID: 16389543 DOI: 10.1007/s00101-005-0962-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Argatroban is a direct, selective and reversible active site thrombin inhibitor derived from L-arginine. It is a representative of a new class of antithrombotic drugs which offer inhibition of clot-bound as well as fluid-phase thrombin. Argatroban is characterised by favourable pharmacokinetics (beta-elimination half-time approximately 40-50 min) undergoing hepatic metabolism and mainly biliary excretion. Renal impairment will not result in altered or delayed elimination. For many years, argatroban has been used in Japan and in the United States and is approved by the FDA for anticoagulation in patients with heparin-induced thrombocytopenia (HIT type II). The ease of monitoring with the activated partial thromboplastin time, lack of induction of antibodies and adequate safety in renal failure patients, make this drug a favourable mode therapy in comparison with other anticoagulants such as lepirudin or heparinoids. Since June 2005 argatroban has been approved in Germany for the treatment of patients with HIT type II. The main characteristics of the drug with special considerations for anaesthesiologists and intensive care physicians are presented in this review.
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Affiliation(s)
- S Kleinschmidt
- Klinik für Anaesthesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg (Saar), Germany.
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Ciccolo ML, Bernstein J, Collazos JC, Acherman RJ, Restrepo H, Winters JM, Krueger J, Evans WN. Argatroban Anticoagulation for Cardiac Surgery with Cardiopulmonary Bypass in an Infant with Double Outlet Right Ventricle and a History of Heparin-induced Thrombocytopenia. CONGENIT HEART DIS 2008; 3:299-302. [DOI: 10.1111/j.1747-0803.2008.00173.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Cornell T, Wyrick P, Fleming G, Pasko D, Han Y, Custer J, Haft J, Annich G. A case series describing the use of argatroban in patients on extracorporeal circulation. ASAIO J 2007; 53:460-3. [PMID: 17667231 DOI: 10.1097/mat.0b013e31805c0d6c] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Anticoagulation for extracorporeal life support (ECLS) is routinely achieved using heparin, which can be difficult in patients suspected of having heparin-induced thrombocytopenia. We describe a case series of five patients in which we used argatroban, a direct thrombin inhibitor, as an alternative to heparin for systemic anticoagulation during ECLS in patients suspected to have heparin-induced thrombocytopenia. Argatroban was used to achieve target systemic anticoagulation for activate clotting times between 210 and 230. Duration of argatroban use while on ECLS ranged from 6 to 184 hours. Argatroban dosage ranged from 0.2 to 3.5 microg/kg/min. Activated clotting times showed good agreement with aPTT. In conclusion, we illustrate that argatroban is a reasonable alternative to heparin anticoagulation for patients requiring ECLS.
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Affiliation(s)
- Timothy Cornell
- Critical Care Medicine, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan 48109, USA
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18
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Harder S, Merz M, Klinkhardt U, Lorenz H, Koster A. Influence of argatroban on coagulation parameters in heparin-induced thrombocytopenia patients after cardiothoracic surgery. J Thromb Haemost 2007; 5:1982-4. [PMID: 17723141 DOI: 10.1111/j.1538-7836.2007.02662.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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19
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Kuhle S, Lau A, Bajzar L, Vegh P, Halton J, Cherrick I, Anderson R, Desai S, McCusker P, Wu J, Abshire T, Mahoney D, Mitchell L. Comparison of the anticoagulant effect of a direct thrombin inhibitor and a low molecular weight heparin in an acquired antithrombin deficiency in children with acute lymphoblastic leukaemia treated with L-asparaginase: an in vitro study. Br J Haematol 2006; 134:526-31. [PMID: 16856890 DOI: 10.1111/j.1365-2141.2006.06209.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Thrombosis occurs in 37% of children with acute lymphoblastic leukaemia (ALL) and is related to an L-asparaginase-induced acquired antithrombin (AT) deficiency. The incidence dictates the need for anticoagulant prophylaxis. Direct thrombin inhibitors (DTI) are independent of AT for effect and may thus have advantages in this population. The objective of this study was to determine the interaction of an AT deficiency with the anticoagulant effects of a DTI and a low molecular weight heparin (LMWH). Plasma samples from children with ALL were pooled (mean AT 0.53 U/ml). LMWH 0.3 and 0.7 U/ml or melagatran 0.3 and 0.5 micromol/l were added to the pools, then divided and AT was added back to one aliquot. In additional experiments, AT was added to AT immuno-depleted plasma. Endogenous thrombin generation capacity (ETGC) was assessed by the continuous method. In plasma with LMWH, there was a 66-88% decrease in ETGC in AT-normalised samples compared with neat. Conversely, no significant difference in ETGC with or without AT added for melagatran was seen. Experiments with AT-depleted plasma showed no effect of AT level on anticoagulant activity of DTI, but a significant relationship for LMWH. By contrast to LMWH, DTI provides a consistent anticoagulant response independent of AT levels in children with AT deficiency.
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Affiliation(s)
- Stefan Kuhle
- Pediatric Thrombosis Program, Stollery Children's Hospital, Edmonton, AB, Canada
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Fareed J, Jeske WP, Hoppensteadt DA, Walenga JM. Update on the clinical applications of argatroban. Future Cardiol 2006; 2:403-14. [DOI: 10.2217/14796678.2.4.403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The small molecule, arginomimetic drug argatroban is the first synthetic direct antithrombin to be approved for clinical use. Argatroban reversibly binds to and inhibits both soluble and clot-bound thrombin. In contrast to other direct thrombin inhibitors, argatroban upregulates nitric oxide, enhancing its antithrombotic effect, does not generate antibodies, is not susceptible to degradation by proteases and is hepatically cleared. It has a predictable anticoagulant effect. Argatroban has proven efficacy and safety for prophylaxis and treatment of patients with thrombosis associated with heparin-induced thrombocytopenia (HIT), and for percutaneous coronary intervention in HIT and non-HIT patients. Pilot studies suggest that further investigations to establish the use of argatroban in ischemic stroke, acute coronary syndrome, hemodialysis, blood oxygenation, off-pump cardiac surgery and other clinical indications are warranted.
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Affiliation(s)
- Jawed Fareed
- Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Walter P Jeske
- Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Debra A Hoppensteadt
- Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Jeanine M Walenga
- Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue, Maywood, IL 60153, USA
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Knoderer CA, Knoderer HM, Turrentine MW, Kumar M. Lepirudin Anticoagulation for Heparin-Induced Thrombocytopenia After Cardiac Surgery in a Pediatric Patient. Pharmacotherapy 2006; 26:709-12. [PMID: 16718945 DOI: 10.1592/phco.26.5.709] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 21-month-old boy received anticoagulation with lepirudin for heparin-induced thrombocytopenia (HIT) after undergoing cardiac surgery and receiving extracorporeal membrane oxygenation (ECMO). This report illustrates the significance of HIT in pediatric patients after cardiac surgery and the successful administration of lepirudin in this setting. To our knowledge, this is the first published report of lepirudin administered to treat HIT in a child after cardiac surgery and ECMO. Although guidelines exist that suggest the potential administration of lepirudin as treatment for children with HIT, further studies are needed to determine the safest yet most effective dosage for this population.
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Affiliation(s)
- Chad A Knoderer
- Department of Pharmacy, Clarian Health Partners, Riley Hospital for Children, Indianapolis, IN 46202, USA.
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Abstract
Argatroban, a direct thrombin inhibitor, is approved in the United States in adults as an anticoagulant for prophylaxis or treatment of thrombosis in heparin-induced thrombocytopenia (HIT) and in adults with or at risk for HIT undergoing percutaneous coronary intervention. The authors conducted a literature analysis to characterize the uses, dosing patterns, and safety of argatroban anticoagulation in pediatric patients. A comprehensive literature search identified nine articles describing 34 patients aged 1 week to 16 years who received argatroban anticoagulation for prophylaxis or treatment of thrombosis, cardiac catheterization, hemodialysis, extracorporeal membrane oxygenation or ventricular assist device support, or cardiopulmonary bypass. Most (85%) patients had HIT, a history of HIT, and/or HIT antibodies. For HIT thromboprophylaxis or treatment, argatroban dosing varied widely (0.1-12 mcg/kg/min), with no obvious relationship between patient age and dosage requirement. Overall, in these pediatric patients, therapeutic levels of anticoagulation were achieved despite the wide range of doses used. For pediatric patients undergoing cardiac catheterization, argatroban doses lower than those recommended in adults appeared to provide therapeutic anticoagulation. There was an unacceptably high bleeding risk with argatroban anticoagulation during pediatric cardiopulmonary bypass. Due to the limitations of case reports and/or case series, prospective studies with pharmacokinetic analyses are needed to evaluate the use of argatroban in pediatric patients.
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