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Hussein HR, Chang CY, Zheng Y, Yang CY, Li LH, Lee YT, Chen JY, Liang YC, Lin CJ, Chang YC, Geo HN, Noor SM, Kiew LV, Chen FR, Chang CC. Immune-stealth VP28-conjugated heparin nanoparticles for enhanced and reversible anticoagulation. NANOTECHNOLOGY 2024; 35:175102. [PMID: 38262054 DOI: 10.1088/1361-6528/ad21a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/23/2024] [Indexed: 01/25/2024]
Abstract
Heparins are a family of sulfated linear negatively charged polysaccharides that have been widely used for their anticoagulant, antithrombotic, antitumor, anti-inflammatory, and antiviral properties. Additionally, it has been used for acute cerebral infarction relief as well as other pharmacological actions. However, heparin's self-aggregated macrocomplex may reduce blood circulation time and induce life-threatening thrombocytopenia (HIT) complicating the use of heparins. Nonetheless, the conjugation of heparin to immuno-stealth biomolecules may overcome these obstacles. An immunostealth recombinant viral capsid protein (VP28) was expressed and conjugated with heparin to form a novel nanoparticle (VP28-heparin). VP28-heparin was characterized and tested to determine its immunogenicity, anticoagulation properties, effects on total platelet count, and risk of inducing HIT in animal models. The synthesized VP28-heparin trimeric nanoparticle was non-immunogenic, possessed an average hydrodynamic size (8.81 ± 0.58 nm) optimal for the evasion renal filtration and reticuloendothelial system uptake (hence prolonging circulating half-life). Additionally, VP28-heparin did not induce mouse death or reduce blood platelet count when administered at a high dosein vivo(hence reducing HIT risks). The VP28-heparin nanoparticle also exhibited superior anticoagulation properties (2.2× higher prothrombin time) and comparable activated partial thromboplastin time, but longer anticoagulation period when compared to unfractionated heparin. The anticoagulative effects of the VP28-heparin can also be reversed using protamine sulfate. Thus, VP28-heparin may be an effective and safe heparin derivative for therapeutic use.
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Affiliation(s)
- Hussein Reda Hussein
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
- Department of Botany and Microbiology, Faculty of Science, Al-Azhar University, Assiut branch 71524, Egypt
| | - Chia-Yu Chang
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
| | - Yini Zheng
- Department of Materials Science and Engineering, City University of Hong Kong, Hong Kong
| | - Chih-Yu Yang
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Li-Hua Li
- Department of Pathology and laboratory medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Yi-Tzu Lee
- Department of Emergency, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Jun-Yi Chen
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yu-Chaun Liang
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 11529, Taiwan
| | - Chuan-Ju Lin
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 11529, Taiwan
| | - Yu-Chia Chang
- Agricultural Biotechnology Research Center, Academia Sinica, Taipei 11529, Taiwan
| | - Hui Nee Geo
- Department of Pharmacology, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Suzita Mohd Noor
- Department of Biomedical Science, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Lik Voon Kiew
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
- Department of Pharmacology, Faculty of Medicine, Universiti Malaya, 50603 Kuala Lumpur, Malaysia
| | - Fu-Rong Chen
- Department of Materials Science and Engineering, City University of Hong Kong, Hong Kong
| | - Chia-Ching Chang
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, 30068 Hsinchu, Taiwan
- Department of Electrophysics, National Yang Ming Chiao Tung University, Hsinchu 30010, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), National Yang Ming Chiao Tung University, Hsinchu 30068, Taiwan
- International College of Semiconductor Technology, National Yang Ming Chiao Tung University, 30010 Hsinchu, Taiwan
- Institute of Physics, Academia Sinica, Taipei 10529, Taiwan
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Graser A, Bauters A, Auffray JL, Vayne C, Provot F, Jourdain M, Robriquet L. Effectiveness and safety of therapeutic plasma exchange to modify the functionality of heparin-induced thrombocytopenia antibodies and correct profound thrombocytopenia: A case report and literature review. JOURNAL OF INTENSIVE MEDICINE 2023; 3:373-375. [PMID: 38028634 PMCID: PMC10658034 DOI: 10.1016/j.jointm.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Audrey Graser
- Department of Intensive Care Medicine, CHU Lille, Lille F-59000, France
| | - Anne Bauters
- Service d'Hémostase-Transfusion, Institut d'Hématologie, Centre de Biologie Pathologie Génétique, Boulevard du Professeur Jules Leclercq, Centre Hospitalier Universitaire de Lille, Lille 59037, France
| | - Jean-Luc Auffray
- Service de Cardiologie, Institut Coeur Poumon, Boulevard du Professeur Jules Leclercq, Centre Hospitalier Universitaire de Lille, Lille 59037, France
| | - Caroline Vayne
- Service d'Hématologie-Hémostase, Centre Hospitalier Universitaire de Tours, Université de Tours, Tours EA4245 T2I, France
| | - François Provot
- Pôle de Néphrologie, Hôpital Albert Calmette, Boulevard du Professeur Jules Leclercq, Centre Hospitalier Universitaire de Lille, Lille 59037, France
| | - Merce Jourdain
- Department of Intensive Care Medicine, Univ Lille, Inserm, CHU Lille, Lille F-59000, France
| | - Laurent Robriquet
- Department of Intensive Care Medicine, CHU Lille, Lille F-59000, France
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Liu L, Zheng H, Chen S, Wang S, Yang M. Heparin-induced thrombocytopenia associated with low-molecular-weight heparin: clinical feature analysis of cases and pharmacovigilance assessment of the FAERS database. Front Pharmacol 2023; 14:1247253. [PMID: 37808193 PMCID: PMC10552922 DOI: 10.3389/fphar.2023.1247253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/30/2023] [Indexed: 10/10/2023] Open
Abstract
Background: Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are commonly used anticoagulants for the management of arterial and venous thromboses. However, it is crucial to be aware that LMWH can, in rare cases, lead to a dangerous complication known as heparin-induced thrombocytopenia (HIT). The objective of this study was to evaluate the pharmacovigilance and clinical features of HIT associated with LMWH, as well as identify treatment strategies and risk factors to facilitate prompt management. Methods: We extracted adverse event report data from the FDA Adverse Event Reporting System (FAERS) database for pharmacovigilance assessment. Case reports on LMWH-induced thrombocytopenia dated up to 20 March 2023 were collected for retrospective analysis. Results: Significantly elevated reporting rates of HIT were shown in adverse event (AE) data of LMWHs in the FAERS database, while tinzaparin had a higher proportional reporting ratio (PRR) and reporting odds ratio (ROR) than other LMWHs, indicating a greater likelihood of HIT. Case report analysis indicated that a total of 43 patients showed evidence of LMWH-induced thrombocytopenia with a median onset time of 8 days. Almost half of the events were caused by enoxaparin. LMWHs were mainly prescribed for the treatment of embolism and thromboprophylaxis of joint operation. Patients with a history of diabetes or surgery appeared to be more susceptible to HIT. Clinical symptoms were mostly presented as thrombus, skin lesion, and dyspnea. Almost 90% of the patients experienced a platelet reduction of more than 50% and had a Warkentin 4T score of more than 6, indicating a high likelihood of HIT. In all patients, LMWHs that were determined to be the cause were promptly withdrawn. Following the discontinuation of LMWHs, almost all patients were given alternative anticoagulants and eventually achieved recovery. Conclusion: LMWH-induced thrombocytopenia is rare but serious, with increased risk in patients with diabetes or a surgical history. Prompt recognition and management are crucial for the safe use of LMWHs.
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Affiliation(s)
- Leping Liu
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hong Zheng
- Department of Pediatrics, The Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Shanshan Chen
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Shengfeng Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Postdoctoral Research Station of Clinical Medicine, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Minghua Yang
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- MOE Key Lab of Rare Pediatric Diseases, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
- Hunan Clinical Research Center of Pediatric Cancer, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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Gbadamosi S, Feick KL. Update on the Treatment of Heparin-Induced Thrombocytopenia. AACN Adv Crit Care 2023; 34:173-178. [PMID: 37644631 DOI: 10.4037/aacnacc2023462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Sheriff Gbadamosi
- Sheriff Gbadamosi is Clinical Pharmacy Specialist-Critical Care, Temple University Hospital Main Campus, 3401 N Broad Street, Philadelphia, PA 19140
| | - Kristin L Feick
- Kristin L. Feick is Clinical Pharmacy Specialist-Critical Care, University of Pittsburgh Medical Center Central Pennsylvania Region
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Mongirdienė A, Liuizė A, Kašauskas A. Novel Knowledge about Molecular Mechanisms of Heparin-Induced Thrombocytopenia Type II and Treatment Targets. Int J Mol Sci 2023; 24:ijms24098217. [PMID: 37175923 PMCID: PMC10179321 DOI: 10.3390/ijms24098217] [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: 02/28/2023] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 05/15/2023] Open
Abstract
Heparin-induced thrombocytopenia type II (HIT II), as stated in the literature, occurs in about 3% of all patients and in 0.1-5% of surgical patients. Thrombosis develops in 20-64% of patients with HIT. The mortality rate in HIT II has not decreased using non-heparin treatment with anticoagulants such as argatroban and lepirudin. An improved understanding of the pathophysiology of HIT may help identify targeted therapies to prevent thrombosis without subjecting patients to the risk of intense anticoagulation. The review will summarize the current knowledge about the pathogenesis of HIT II, potential new therapeutic targets related to it, and new treatments being developed. HIT II pathogenesis involves multi-step immune-mediated pathways dependent on the ratio of PF4/heparin and platelet, monocyte, neutrophil, and endothelium activation. For years, only platelets were known to take part in HIT II development. A few years ago, specific receptors and signal-induced pathways in monocytes, neutrophils and endothelium were revealed. It had been shown that the cells that had become active realised different newly formed compounds (platelet-released TF, TNFα, NAP2, CXCL-7, ENA-78, platelet-derived microparticles; monocytes-TF-MPs; neutrophils-NETs), leading to additional cell activation and consequently thrombin generation, resulting in thrombosis. Knowledge about FcγIIa receptors on platelets, monocytes, neutrophils and FcγIIIa on endothelium, chemokine (CXCR-2), and PSGL-1 receptors on neutrophils could allow for the development of a new non-anticoagulant treatment for HIT II. IgG degradation, Syk kinase and NETosis inhibition are in the field of developing new treatment possibilities too. Accordingly, IdeS and DNases-related pathways should be investigated for better understanding of HIT pathogenesis and the possibilities of being the HIT II treatment targets.
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Affiliation(s)
- Aušra Mongirdienė
- Department of Biochemistry, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania
| | - Agnė Liuizė
- Medicine Academy, Lithuanian University of Health Sciences, Eiveniu Str. 4, LT-50103 Kaunas, Lithuania
| | - Artūras Kašauskas
- Department of Biochemistry, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania
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Besch G, Ilic D, Ginet M, d’Audigier C, Nguyen P, Ferreira D, Samain E, Mourey G, Pili-Floury S. Identification of Heparin-Induced Thrombocytopenia in Surgical Critically Ill Patients by Using the HIT Expert Probability Score: An Observational Pilot Study. J Clin Med 2022; 11:jcm11061515. [PMID: 35329842 PMCID: PMC8951334 DOI: 10.3390/jcm11061515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/03/2022] [Accepted: 03/06/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Heparin-induced thrombocytopenia (HIT) remains a challenging diagnosis especially in surgical intensive care unit (SICU) patients. The aim of the study was to evaluate for the first time the diagnostic accuracy of the HIT Expert Probability (HEP) score in the early identification of HIT in SICU patients. Methods: The HEP and 4Ts scores were calculated in all patients with suspected HIT during their stay in our SICU. The diagnosis of HIT was finally confirmed (HIT+ group) or excluded (HIT− group) by an independent committee blinded to the HEP and 4Ts score values. The primary outcome was the sensitivity and specificity of a HEP score ≥ 5 for the diagnosis of HIT. The secondary outcome was the area under the ROC curve (AUC) of the HEP and 4Ts scores in the diagnosis of HIT. Results: Respectively 6 and 113 patients were included in the HIT+ and HIT− groups. A HEP score value ≥ 5 had a sensitivity (95% confidence interval (95% CI)) of 1.00 (0.55−1.00), and a specificity (95% CI) of 0.92 (0.86−0.96). The AUC (95% CI) was significantly higher for the HEP score versus for the 4Ts score (0.967 (0.922−1.000) versus 0.707 (0.449−0.965); p = 0.035). Conclusions: A HEP score value < 5 could be helpful to rule out HIT in SICU patients.
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Affiliation(s)
- Guillaume Besch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, F-25000 Besancon, France; (D.I.); (M.G.); (D.F.); (E.S.); (S.P.-F.)
- EA3920, University of Franche-Comte, 3 bvd Alexander Fleming, F-25000 Besancon, France
- Correspondence:
| | - Dejan Ilic
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, F-25000 Besancon, France; (D.I.); (M.G.); (D.F.); (E.S.); (S.P.-F.)
| | - Marc Ginet
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, F-25000 Besancon, France; (D.I.); (M.G.); (D.F.); (E.S.); (S.P.-F.)
| | - Clément d’Audigier
- Etablissement Français du Sang Bourgogne Franche-Comté, Hemostasis Department, Laboratoire de Biologie Médicale et de Greffe, F-25000 Besançon, France; (C.d.); (G.M.)
| | - Philippe Nguyen
- Department of Haematology, CHU Robert Debré, F-51000 Reims, France;
- EA3801, IFR-53, Reims Champagne-Ardenne University, F-51000 Reims, France
| | - David Ferreira
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, F-25000 Besancon, France; (D.I.); (M.G.); (D.F.); (E.S.); (S.P.-F.)
- EA481, Integrative and Clinical Neuroscience Laboratory, University Hospital of Besancon, F-25000 Besancon, France
| | - Emmanuel Samain
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, F-25000 Besancon, France; (D.I.); (M.G.); (D.F.); (E.S.); (S.P.-F.)
- EA3920, University of Franche-Comte, 3 bvd Alexander Fleming, F-25000 Besancon, France
| | - Guillaume Mourey
- Etablissement Français du Sang Bourgogne Franche-Comté, Hemostasis Department, Laboratoire de Biologie Médicale et de Greffe, F-25000 Besançon, France; (C.d.); (G.M.)
- Department of Clinical Hemostasis, University Hospital of Besancon, F-25000 Besancon, France
| | - Sebastien Pili-Floury
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, F-25000 Besancon, France; (D.I.); (M.G.); (D.F.); (E.S.); (S.P.-F.)
- EA3920, University of Franche-Comte, 3 bvd Alexander Fleming, F-25000 Besancon, France
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7
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Tyrosine-O-sulfation is a widespread affinity enhancer among thrombin interactors. Biochem Soc Trans 2022; 50:387-401. [PMID: 34994377 DOI: 10.1042/bst20210600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 12/24/2022]
Abstract
Tyrosine-O-sulfation is a common post-translational modification (PTM) of proteins following the cellular secretory pathway. First described in human fibrinogen, tyrosine-O-sulfation has long been associated with the modulation of protein-protein interactions in several physiological processes. A number of relevant interactions for hemostasis are largely dictated by this PTM, many of which involving the serine proteinase thrombin (FIIa), a central player in the blood-clotting cascade. Tyrosine sulfation is not limited to endogenous FIIa ligands and has also been found in hirudin, a well-known and potent thrombin inhibitor from the medicinal leech, Hirudo medicinalis. The discovery of hirudin led to successful clinical application of analogs of leech-inspired molecules, but also unveiled several other natural thrombin-directed anticoagulant molecules, many of which undergo tyrosine-O-sulfation. The presence of this PTM has been shown to enhance the anticoagulant properties of these peptides from a range of blood-feeding organisms, including ticks, mosquitos and flies. Interestingly, some of these molecules display mechanisms of action that mimic those of thrombin's bona fide substrates.
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Munafo N, Patel S, Willett KC, Morrill A. Oral Factor Xa (FXa) Inhibitors for Treatment of Heparin-induced Thrombocytopenia (HIT). CURRENT DRUG THERAPY 2021. [DOI: 10.2174/1574885515999201210213348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background::
Heparin is the most commonly used injectable anticoagulant for many indications,
ranging from the treatment of atrial fibrillation to the prevention of clotting in patients
undergoing surgery. Currently, only argatroban and bivalirudin are FDA approved for the management
of heparin induced thrombocytopenia (HIT) in the United States, both of which are direct
thrombin inhibitors. The agents being reviewed, apixaban and rivaroxaban, are oral direct factor
Xa (FXa) inhibitors. Currently, neither has FDA approval for use in HIT. The objective of this review
is to summarize the current evidence available regarding the use of oral factor Xa inhibitors
for the treatment of HIT.
Methods::
A literature search was conducted using Medline and Ovid Embase. Search terms included
heparin-induced thrombocytopenia, HIT, apixaban, rivaroxaban, Xa Inhibitor, direct thrombin
inhibitor, NOAC, and DOAC. Studies and case reports were included if they evaluated the efficacy
and safety of oral FXa inhibitors for the treatment of HIT. Additional literature and case reports
were found through bibliographic review.
Results and Discussion:
Currently, available literature includes an in vitro study with apixaban,
case reports, and retrospective and prospective cohort studies. The in vitro study evaluated the interaction
between apixaban and platelets in the presence of HIT antibodies, which assessed its potential
for use in HIT management. Fourteen case reports and one case series were also identified, of
which six described treatment with apixaban and eight with rivaroxaban. Lastly, four cohort
studies were published evaluating the use of direct acting oral anticoagulants (DOACs), including
oral factor Xa inhibitors in patients with HIT. Although there are no published randomized control
trials evaluating the use of FXa inhibitors in the management of HIT, there are several findings that
may guide clinicians on the use of these agents in practice.
Conclusion::
As indicated by the case reports, case series and cohort studies detailing clinical use
and described in this manuscript, there are data and positive patient outcomes that support the potential
use of these agents for HIT, and are an impetus for future studies.
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Affiliation(s)
- Nicholas Munafo
- Department of Pharmacy Practice, MCPHS University School of Pharmacy Worcester/Manchester, 19 Foster Street Worcester, MA, 01608, United States
| | - Sagar Patel
- Department of Pharmacy Practice, MCPHS University School of Pharmacy–Worcester/- Manchester Sanofi Genzyme, Cambridge, MA, United States
| | - Kristine C. Willett
- Department of Pharmacy Practice MCPHS University, School of Pharmacy – Worcester/Manchester, United States
| | - Amanda Morrill
- Department of Pharmacy Practice MCPHS University, School of Pharmacy – Worcester/Manchester, United States
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Nilius H, Kaufmann J, Cuker A, Nagler M. Comparative effectiveness and safety of anticoagulants for the treatment of heparin-induced thrombocytopenia. Am J Hematol 2021; 96:805-815. [PMID: 33857342 PMCID: PMC8252596 DOI: 10.1002/ajh.26194] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The effectiveness and safety of non-heparin anticoagulants for the treatment of heparin-induced thrombocytopenia (HIT) are not fully established, and the optimal treatment strategy is unknown. In a systematic review and meta-analysis, we aimed to determine precise rates of platelet recovery, new or progressive thromboembolism (TE), major bleeding, and death for all non-heparin anticoagulants and to study potential sources of variability. METHODS Following a detailed protocol (PROSPERO: CRD42020219027), EMBASE and Medline were searched for all studies reporting clinical outcomes of patients treated with non-heparin anticoagulants (argatroban, danaparoid, fondaparinux, direct oral anticoagulants [DOAC], bivalirudin, and other hirudins) for acute HIT. Proportions of patients with the outcomes of interest were pooled using a random-effects model for each drug. The influence of the patient population, the diagnostic test used, the study design, and the type of article was assessed. RESULTS Out of 3194 articles screened, 92 studies with 119 treatment groups describing 4698 patients were included. The pooled rates of platelet recovery ranged from 74% (bivalirudin) to 99% (fondaparinux), TE from 1% (fondaparinux) to 7% (danaparoid), major bleeding from 1% (DOAC) to 14% (bivalirudin), and death from 7% (fondaparinux) to 19% (bivalirudin). Confidence intervals were mostly overlapping, and results were not influenced by patient population, diagnostic test used, study design, or type of article. DISCUSSION Effectiveness and safety outcomes were similar among various anticoagulants, and significant factors affecting these outcomes were not identified. These findings support fondaparinux and DOACs as viable alternatives to conventional anticoagulants for treatment of acute HIT in clinical practice.
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Affiliation(s)
- Henning Nilius
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
| | - Jonas Kaufmann
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Michael Nagler
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
- University of BernBernSwitzerland
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10
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Management of heparin-induced thrombocytopenia: systematic reviews and meta-analyses. Blood Adv 2021; 4:5184-5193. [PMID: 33095876 DOI: 10.1182/bloodadvances.2020002963] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic adverse drug reaction occurring in <0.1% to 7% of patients receiving heparin products depending on the patient population and type of heparin. Management of HIT is highly dependent on a sequence of tests for which clinicians may or may not have the results when care decisions need to be made. We conducted systematic reviews of the effects of management strategies in persons with acute HIT, subacute HIT A or B, and remote HIT. We searched Medline, EMBASE, and the Cochrane Database through July 2019 for previously published systematic reviews and primary studies. Two investigators independently screened and extracted data and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. We found primarily noncomparative studies and case series assessing effects of treatments, which led to low to very low certainty evidence. There may be little to no difference in the effects between nonheparin parenteral anticoagulants and direct oral anticoagulants in acute HIT. The benefits of therapeutic-intensity may be greater than prophylactic-intensity anticoagulation. Using inferior vena cava filters or platelet transfusion may result in greater harm than not using these approaches. Evidence for management in special situations, such as for patients undergoing cardiovascular interventions or renal replacement therapy, was also low to very low certainty. Additional research to evaluate nonheparin anticoagulants is urgently needed, and the development of novel treatments that reduce thrombosis without increasing hemorrhage should be a priority.
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11
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Junren C, Xiaofang X, Huiqiong Z, Gangmin L, Yanpeng Y, Xiaoyu C, Yuqing G, Yanan L, Yue Z, Fu P, Cheng P. Pharmacological Activities and Mechanisms of Hirudin and Its Derivatives - A Review. Front Pharmacol 2021; 12:660757. [PMID: 33935784 PMCID: PMC8085555 DOI: 10.3389/fphar.2021.660757] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/22/2021] [Indexed: 12/13/2022] Open
Abstract
Hirudin, an acidic polypeptide secreted by the salivary glands of Hirudo medicinalis (also known as "Shuizhi" in traditional Chinese medicine), is the strongest natural specific inhibitor of thrombin found so far. Hirudin has been demonstrated to possess potent anti-thrombotic effect in previous studies. Recently, increasing researches have focused on the anti-thrombotic activity of the derivatives of hirudin, mainly because these derivatives have stronger antithrombotic activity and lower bleeding risk. Additionally, various bioactivities of hirudin have been reported as well, including wound repair effect, anti-fibrosis effect, effect on diabetic complications, anti-tumor effect, anti-hyperuricemia effect, effect on cerebral hemorrhage, and others. Therefore, by collecting and summarizing publications from the recent two decades, the pharmacological activities, pharmacokinetics, novel preparations and derivatives, as well as toxicity of hirudin were systematically reviewed in this paper. In addition, the clinical application, the underlying mechanisms of pharmacological effects, the dose-effect relationship, and the development potential in new drug research of hirudin were discussed on the purpose of providing new ideas for application of hirudin in treating related diseases.
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Affiliation(s)
- Chen Junren
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xie Xiaofang
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhang Huiqiong
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Li Gangmin
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yin Yanpeng
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Cao Xiaoyu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Gao Yuqing
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Li Yanan
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhang Yue
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Peng Fu
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China.,West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Peng Cheng
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu, China.,Chengdu University of Traditional Chinese Medicine, Chengdu, China
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12
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Zhang X, Jin Q, Kong D, Pan C, Zhang X, Zhou D, Shen Z, Zhou D, Ge J. Clinical outcomes of bivalirudin versus heparin in atrial fibrillation patients undergoing percutaneous left atrial appendage occlusion. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:629. [PMID: 33987327 PMCID: PMC8106030 DOI: 10.21037/atm-20-4755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Prior studies have suggested that patients with atrial fibrillation (AF) referred for left atrial appendage occlusion (LAAO) are confronted with considerable risk of periprocedural thromboembolism and hemmorhagic events. The purpose of this study was to evaluate the safety and feasibility of bivalirudin during LAAO. Methods This retrospective, observational study included 420 AF patients who were evaluated as being at high risk of stroke or bleeding and indicated for LAAO at our center between June 2018 and June 2019 (158 with bivalirudin and 262 with heparin). The primary outcome was the incidence of any bleeding within 48 hours of LAAO. Secondary outcomes were major adverse cardiac events (MACE) between 48 hours and 60 days post-procedure and overall bleeding events during follow up. Results No significant difference was observed between bivalirudin and heparin for major periprocedural bleeding (1.27% for bivalirudin vs. 2.29% for heparin, P=0.716) or minor bleeding (1.27% vs. 1.15%, P>0.9). At 48 hours post-procedure, strokes occurred at a rate of 0.63% in the bivalirudin group and 1.15% in the heparin group (P>0.9), and one case treated with bivalirudin developed systemic embolization. At 60 days, the rates of MACE (1.90% vs. 2.29%, P>0.9), a device-related thrombus (DRT) (1.27% vs. 1.52%, P>0.9), and overall bleeding events (5.06% vs. 4.96%, P=0.963) were comparable between the 2 cohorts. Upon Kaplan-Meier survival analysis, early safety during the 60-day follow-up was 93.67% in the bivalirudin group and 91.60% in the heparin group (P=0.570). Conclusions Bivalirudin has a comparable safety and efficacy profile to heparin as an intraprocedural anticoagulant, but currently, it should still be reserved for patients in which heparin is contraindicated.
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Affiliation(s)
- Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Shanghai, China
| | - Qinchun Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Shanghai, China
| | - Dehong Kong
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Cuizhen Pan
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xian Zhang
- Department of Cardiac Echocardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dan Zhou
- Department of Cardiac Echocardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiyun Shen
- Department of Cardiac Echocardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Research Unit of Cardiovascular Techniques and Devices, Chinese Academy of Medical Sciences, Shanghai, China
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13
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Hvas AM, Favaloro EJ, Hellfritzsch M. Heparin-induced thrombocytopenia: pathophysiology, diagnosis and treatment. Expert Rev Hematol 2021; 14:335-346. [PMID: 33736552 DOI: 10.1080/17474086.2021.1905512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Immune-mediated heparin-induced thrombocytopenia (HIT) is an infrequent complication following heparin exposure but with potentially fatal outcome due to thrombotic complications. Prompt suspension of heparin is necessary if HIT is suspected, followed by initiation of non-heparin anticoagulant therapy.Areas covered: In this review, the pathophysiology and challenges in diagnosing HIT are elucidated. Current and emerging treatment options are discussed with special focus on parenteral thrombin inhibitors (argatroban, bivalirudin), parenteral factor Xa inhibitors (danaparoid, fondaparinux) and direct oral anticoagulants (DOACs [rivaroxaban, apixaban, dabigatran]) including dosing strategies for DOACs. The database PubMed was employed without time boundaries.Expert opinion: Only argatroban holds regulatory approval for HIT treatment in both U.S. and Europe. This treatment is, however, challenged by the need for close monitoring and high costs. Fondaparinux has been increasingly used for off-label treatment and during recent years, evidence for the use of DOACs has emerged. Preliminary results from observational studies hold promise for future use of DOACs in the acute and subacute phase of HIT. However, so far, the use of DOACs in acute HIT should be reserved for clinically stable patients without severe thrombotic complications. Importantly, both fondaparinux and DOAC use is contraindicated in severe renal insufficiency.
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Affiliation(s)
- Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University. Address: Palle Juul-Jensens Boulevard 99, Aarhus N, Denmark
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, Australia
| | - Maja Hellfritzsch
- Department of Cardiology, Herning Regional Hospital, Herning, Denmark
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14
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Marcucci R, Berteotti M, Gori AM, Giusti B, Rogolino AA, Sticchi E, Liotta AA, Ageno W, De Candia E, Gresele P, Marchetti M, Marietta M, Tripodi A. Heparin induced thrombocytopenia: position paper from the Italian Society on Thrombosis and Haemostasis (SISET). BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2021; 19:14-23. [PMID: 33370230 PMCID: PMC7850929 DOI: 10.2450/2020.0248-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/14/2020] [Indexed: 12/21/2022]
Abstract
Heparin induced thrombocytopenia (HIT) is a rare immune mediated adverse drug reaction occurring after exposure to heparin. It is a serious and potentially fatal condition, which may be associated with the development of arterial or venous thrombotic events. Although known for many years, HIT is still often misdiagnosed. Pre- test clinical probability, screening for anti-PF4/heparin antibodies and documentation of their platelet activating capacity are the cornerstones of diagnosis. However, both clinical algorithms and test modalities have limited predictive values and limited diffusion so that the diagnosis and management is challenging in the clinical practice. For this reason, there is an unmet need for novel rational non-anticoagulant therapies based on the pathogenesis of HIT.The present paper reports the position of the Italian Society on Haemostasis and Thrombosis (SISET) in order to increase awareness of HIT among clinicians and other health care professionals and to provide information on the most appropriate management.
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Affiliation(s)
- Rossella Marcucci
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Martina Berteotti
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Anna M. Gori
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Betti Giusti
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Angela A. Rogolino
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Elena Sticchi
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Agatina Alessandrello Liotta
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Erica De Candia
- Department of Translational Medicine and Surgery, Catholic University of Rome, Rome, Italy
- Department of Image Diagnostics, Radiotherapy and Haematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Marina Marchetti
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Marietta
- Department of Oncology and Haematology, University Hospital, Modena, Italy
| | - Armando Tripodi
- IRCCS “Ca’ Granda Maggiore” Hospital Foundation, “Angelo Bianchi Bonomi” Haemophilia and Thrombosis Center and “Fondazione Luigi Villa”, Milan, Italy
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15
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Song CG, Bi LJ, Zhao JJ, Wang X, Li W, Yang F, Jiang W. The efficacy and safety of Hirudin plus Aspirin versus Warfarin in the secondary prevention of Cardioembolic Stroke due to Nonvalvular Atrial Fibrillation: A multicenter prospective cohort study. Int J Med Sci 2021; 18:1167-1178. [PMID: 33526977 PMCID: PMC7847633 DOI: 10.7150/ijms.52752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/22/2020] [Indexed: 11/05/2022] Open
Abstract
Background: To investigate the efficacy and safety of hirudin plus aspirin therapy compared with warfarin in the secondary prevention of cardioembolic stroke due to nonvalvular atrial fibrillation (NVAF). Methods: Patients with cardioembolic stroke due to NVAF were prospectively enrolled from 18 collaborating hospitals from Dec 2011 to June 2015. Fourteen days after stroke onset, eligible patients were assigned to the hirudin plus aspirin group (natural hirudin prescribed as the traditional Chinese medicine Maixuekang capsule, 0.75 g, three times daily, combined with aspirin 100 mg, once daily) or the warfarin group (dose-adjusted warfarin targeting international normalized ratio (INR) 2-3, with an initial daily dose of 1.25 mg). Patients were followed up at 1, 2, 3, 6, 9, and 12 months after stroke onset. Time in therapeutic range (TTR) was calculated according to Rosendaal methodology to evaluate the quality of INR management in the warfarin group. The primary efficacy endpoint was the recurrence of stroke within 12 months after stroke onset. Safety was assessed as the occurrence of the composite event "intracranial hemorrhage and other bleeding events, death, and other serious adverse events". The Cox proportional hazard model and Kaplan-Meier curve were used to analyze the efficacy and safety events. Results: A total of 221 patients entered final analysis with 112 patients in the hirudin plus aspirin group and 109 in the warfarin group. Over the whole duration of our study, TTR for patients taking warfarin was 66.5 % ± 21.5%. A significant difference was not observed in the recurrence of stroke between the two groups (3.57% vs. 2.75%; P = 0.728). The occurrence of safety events was significantly lower in the hirudin plus aspirin group (2.68% vs.10.09%; P = 0.024). The risk for efficacy event was similar between the two groups (hazard ratio (HR), 1.30; 95% confidence interval (CI), 0.29-5.80). The safety risk was significantly lower in the hirudin plus aspirin group (HR, 0.27; 95% CI, 0.07-0.95). Kaplan-Meier analysis revealed significant difference in the temporal distribution in safety events (P = 0.023) but not in stroke recurrence (P = 0.726). Conclusion: Significant difference in efficacy was not detected between warfarin group and hirudin plus aspirin group. Compared with warfarin, hirudin plus aspirin therapy had lower safety risk in the secondary prevention of cardioembolic stroke due to NVAF.
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Affiliation(s)
- Chang-Geng Song
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Li-Jie Bi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jing-Jing Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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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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18
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Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med 2020; 25:160-173. [PMID: 32195628 DOI: 10.1177/1358863x19898253] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
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Affiliation(s)
- Marie Hogan
- Department of Pediatrics, Division of Hematology Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology and Hematology, New York University School of Medicine, New York, NY, USA
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19
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Liu Y, Lu H, Xu H, Fu Z, Zhang D, Jiang B. Heparin-induced thrombocytopenia and acute colonic pseudo-obstruction after therapeutic anticoagulation in a very elderly patient with hip fracture: a case report. BMC Musculoskelet Disord 2020; 21:85. [PMID: 32033561 PMCID: PMC7007645 DOI: 10.1186/s12891-020-3117-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hip fractures have become a severe public health problem, especially in very elderly patients. Most of them are treated with low molecular weight heparin as prophylaxis or treatment of venous thromboembolism. Heparin-induced thrombocytopenia is one of the complications induced by low molecular weight heparin, which may cause poor prognosis. However, there is not enough awareness for heparin-induced thrombocytopenia in very elderly trauma patients. CASE PRESENTATION We report a case of hip fracture with heparin-induced thrombocytopenia in a very elderly patient. The patient developed heparin-induced thrombocytopenia, digestive hemorrhage and acute colonic pseudo-obstruction after the use of low molecular weight heparin, which eventually led to death. CONCLUSIONS This is the first case report of digestive hemorrhage and acute colonic pseudo-obstruction in heparin-induced thrombocytopenia patients with major trauma. This case highlights the severity of HIT in very elderly patients with hip fractures using low molecular weight heparin, and the need for platelet monitoring in these patients. We indicate that there may be a correlation of pathogenesis between digestive hemorrhage and acute colonic pseudo-obstruction in heparin-induced thrombocytopenia patients.
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Affiliation(s)
- Yijun Liu
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hao Lu
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Hailin Xu
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, 100044, China.
| | - Zhongguo Fu
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, 100044, China
| | - Dianying Zhang
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, 100044, China.
| | - Baoguo Jiang
- Department of Orthopaedics and Trauma, Peking University People's Hospital, Beijing, 100044, China.
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20
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Small BL, Gomes MP, McCurry KR, Han X, Ataya A, Akindipe O, Lane CR, Budev M. A Novel Diagnostic Algorithm for Heparin-Induced Thrombocytopenia in a Retrospective Cohort of Lung Transplant Recipients. Prog Transplant 2019; 30:4-12. [PMID: 31838929 DOI: 10.1177/1526924819892918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Heparin-induced thrombocytopenia (HIT) is characterized by thrombocytopenia and potential for thromboembolism. Lung transplant recipients are at risk of developing HIT due to heparin exposure peritransplant. We describe the incidence and impact of HIT in lung transplant recipient index hospital length of stay and survival. DESIGN A retrospective cohort was obtained from electronic medical records which were queried for all recipients treated with bivalirudin (institutional treatment of choice for HIT) between January 1, 2005, and February 16, 2017 (N = 1171). Patients who developed HIT >30 days after transplant or after their index transplant admission were excluded. A diagnostic algorithm was used retrospectively to determine clinical HIT with an intermediate or high pretest clinical suspicion ("4T" score ≥4) and either (1) positive anti-heparin-platelet-factor 4 (HPF4) assay and a positive functional platelet assay or (2) a positive HPF4 assay only, in patients who did not undergo cardiopulmonary bypass. RESULTS Among all lung transplant recipients, 2.1% were found to develop HIT in the peritransplant period (N = 25, mean = 88%) with a mean lung allocation score of 50.8 and an incidence of venous thromboembolism of 72%, most upper extremity in location. When matched with historical controls, patients with HIT had a longer overall index hospital length of stay of 43 days (P = .008). There was no difference in short- or long-term survival posttransplant. CONCLUSION Vigilance for the development of HIT in lung transplant recipients is necessary to prevent further morbidity from thromboembolic events. In our cohort, HIT increased hospital length of stay but did not appear to affect recipient survival.
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Affiliation(s)
- Bronwyn Larissa Small
- Pulmonary, Critical Care and Allergy Department, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marcelo P Gomes
- Department of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kenneth R McCurry
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaozhen Han
- Biostatistics Core, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Ataya
- Department of Pulmonary, Critical Care and Allergy, University of Florida, Gainesville, FL, USA
| | - Olufemi Akindipe
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - C Randall Lane
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marie Budev
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Guo Q, Lou Y, Liu L, Luo P. How Can I Manage Thrombocytopenia in Hemodialysis Patient? A Review. Ther Apher Dial 2019; 24:352-360. [PMID: 31661590 DOI: 10.1111/1744-9987.13448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Qiaoyan Guo
- Department of NephrologyJilin University Second Hospital Changchun China
| | - Yan Lou
- Department of NephrologyJilin University Second Hospital Changchun China
| | - Lihua Liu
- Department of NephrologyJilin University Second Hospital Changchun China
| | - Ping Luo
- Department of NephrologyJilin University Second Hospital Changchun China
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22
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Risk Factors and Outcomes Associated with Prolonged Subtherapeutic Anticoagulation with Bivalirudin: A Retrospective Cohort Study. Pharmacotherapy 2019; 39:1157-1166. [DOI: 10.1002/phar.2335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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23
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Pishko AM, Lefler DS, Gimotty P, Paydary K, Fardin S, Arepally GM, Crowther M, Rice L, Vega R, Cines DB, Guevara JP, Cuker A. The risk of major bleeding in patients with suspected heparin-induced thrombocytopenia. J Thromb Haemost 2019; 17:1956-1965. [PMID: 31350937 PMCID: PMC6913895 DOI: 10.1111/jth.14587] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/22/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND The presence of a hypercoagulable disorder such as heparin-induced thrombocytopenia (HIT) may protect against anticoagulant-associated bleeding. OBJECTIVES To determine the incidence of major bleeding in patients with suspected HIT. METHODS We performed a retrospective analysis of 310 patients suspected of having HIT from the Hospital of the University of Pennsylvania and an affiliated community hospital. We compared the cumulative incidence of major bleeding following suspicion for HIT by ultimate HIT status (HIT+ or HIT-) and exposure to an alternative anticoagulant (Tx+ or Tx-). Secondary outcomes included the incidence of new/progressive thrombosis and 30-day mortality. RESULTS The incidence of major bleeding was high in the HIT+Tx+, HIT- Tx+, and HIT-Tx- groups (35.7%, 44.0%, and 37.3%, respectively). The time to first major bleeding event did not differ between groups (P = .24). Factors associated with increased risk of major bleeding included intensive care unit admission (HR 2.24, 95% CI 1.44-3.47), platelet count < 25 × 109 /L (HR 2.13, 1.10-4.12), and renal dysfunction (HR 1.56, 1.06-2.27); 35.7% of HIT+Tx+, 13.8% HIT-Tx+, and 9.3% of HIT-Tx- patients experienced new or progressive thrombosis. Mortality was similar among the three groups (26.2% HIT+Tx+, 34.5% HIT-Tx+, and 26.7% of HIT-Tx- [P = .34]). CONCLUSIONS Among patients with suspected HIT, major bleeding was common regardless of HIT status. Contrary to our hypothesis, HIT+ patients were not protected from major bleeding. A better understanding of bleeding risk is needed to inform management decisions in patients with suspected HIT.
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Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel S Lefler
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Phyllis Gimotty
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Koosha Paydary
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Sara Fardin
- Department of Radiology, Tufts Medical Center, Boston, Massachusetts
| | - Gowthami M Arepally
- Division of Hematology, Department of Medicine, Duke University, Durham, North Carolina
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Rice
- Hematology Division, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medical College, Houston, Texas
| | - Rolando Vega
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas B Cines
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James P Guevara
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Duewell BE, Briski MJ, Feih JT, Rinka JRG, Tawil JN. Argatroban Versus Bivalirudin in the Treatment of Suspected or Confirmed Heparin-Induced Thrombocytopenia. J Pharm Pract 2019; 34:529-534. [DOI: 10.1177/0897190019882866] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Argatroban and bivalirudin are direct thrombin inhibitors (DTIs) used for the treatment of heparin-induced thrombocytopenia (HIT). The purpose of this study was to determine whether either agent offered an advantage in efficacy and ability to remain within the targeted therapeutic anticoagulation range. Methods: This was a single-center, retrospective, observational cohort study at a large academic medical center. The primary efficacy outcome was time to therapeutic anticoagulation, defined as total number of hours to achieve 2 consecutive activated partial thromboplastin time (aPTT) values in goal range. Results: A total of 91 patients were included in the analysis. Average time to initial therapeutic anticoagulation was 4.71 hours and 9.8 hours for the argatroban and bivalirudin groups, respectively ( P < .01). Conclusions: Argatroban may be advantageous compared to bivalirudin in achieving initial therapeutic anticoagulation goals among patients with suspected or confirmed HIT.
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Affiliation(s)
| | - Matthew J. Briski
- Department of Pharmacy, The University of Kansas Health System, KS, USA
| | - Joel T. Feih
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joseph R. G. Rinka
- Department of Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, WI, USA
| | - Justin N. Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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Solanki J, Shenoy S, Downs E, Palkimas S, Goldman S, Sharma AM. Heparin-Induced Thrombocytopenia and Cardiac Surgery. Semin Thorac Cardiovasc Surg 2019; 31:335-344. [DOI: 10.1053/j.semtcvs.2018.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/16/2018] [Indexed: 12/16/2022]
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Cuker A, Arepally GM, Chong BH, Cines DB, Greinacher A, Gruel Y, Linkins LA, Rodner SB, Selleng S, Warkentin TE, Wex A, Mustafa RA, Morgan RL, Santesso N. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv 2018; 2:3360-3392. [PMID: 30482768 PMCID: PMC6258919 DOI: 10.1182/bloodadvances.2018024489] [Citation(s) in RCA: 351] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/14/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction mediated by platelet-activating antibodies that target complexes of platelet factor 4 and heparin. Patients are at markedly increased risk of thromboembolism. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about diagnosis and management of HIT. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 33 recommendations. The recommendations address screening of asymptomatic patients for HIT, diagnosis and initial management of patients with suspected HIT, treatment of acute HIT, and special situations in patients with acute HIT or a history of HIT, including cardiovascular surgery, percutaneous cardiovascular intervention, renal replacement therapy, and venous thromboembolism prophylaxis. CONCLUSIONS Strong recommendations include use of the 4Ts score rather than a gestalt approach for estimating the pretest probability of HIT and avoidance of HIT laboratory testing and empiric treatment of HIT in patients with a low-probability 4Ts score. Conditional recommendations include the choice among non-heparin anticoagulants (argatroban, bivalirudin, danaparoid, fondaparinux, direct oral anticoagulants) for treatment of acute HIT.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Beng H Chong
- Department of Haematology, University of New South Wales, Sydney, NSW, Australia
| | - Douglas B Cines
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Yves Gruel
- Department of Haematology-Haemostasis, Trousseau Hospital, Tours, France
| | - Lori A Linkins
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Sixten Selleng
- Department of Anaesthesiology, University of Greifswald, Greifswald, Germany
| | - Theodore E Warkentin
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
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Xu P, Huang M. Small Peptides as Modulators of Serine Proteases. Curr Med Chem 2018; 27:3686-3705. [PMID: 30332941 DOI: 10.2174/0929867325666181016163630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/26/2018] [Accepted: 10/09/2018] [Indexed: 02/08/2023]
Abstract
Serine proteases play critical roles in many physiological and pathological processes, and are proven diagnostic and therapeutic targets in a number of clinical indications. Suppression of the aberrant proteolytic activities of these proteases has been clinically used for the treatments of relevant diseases. Polypeptides with 10-20 residues are of great interests as medicinal modulators of serine proteases, because these peptides demonstrate the characteristics of both small molecule drugs and macromolecular drugs. In this review, we summarized the recent development of peptide-based inhibitors against serine proteases with potent inhibitory and high specificity comparable to monoclonal antibodies. In addition, we also discussed the strategies of enhancing plasma half-life and bioavailability of peptides in vivo, which is the main hurdle that limits the clinical translation of peptide-based drugs. This review advocates new avenue for the development of effective serine protease inhibitors and highlights the prospect of the medicinal use of these inhibitors.
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Affiliation(s)
- Peng Xu
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350116, China
| | - Mingdong Huang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350116, China
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Dhakal B, Kreuziger LB, Rein L, Kleman A, Fraser R, Aster RH, Hari P, Padmanabhan A. Disease burden, complication rates, and health-care costs of heparin-induced thrombocytopenia in the USA: a population-based study. LANCET HAEMATOLOGY 2018; 5:e220-e231. [PMID: 29703336 DOI: 10.1016/s2352-3026(18)30046-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia can be a life-threatening and limb-threatening complication of heparin therapy. Incidence and complication rates of this condition have been extrapolated from studies with modest sample sizes, and despite the availability of therapeutic interventions the outcomes of heparin-induced thrombocytopenia are not well understood. We aimed to estimate disease burden, complication rates, and costs of heparin-induced thrombocytopenia in the USA. METHODS In this population-based study we analysed data from 2009 to 2013 from the Nationwide (National) Inpatient Sample (NIS), a large, all-payer inpatient health-care database in the USA. To validate the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for heparin-induced thrombocytopenia (289.84), we defined the sensitivity and specificity of this code using patient data from 2013 from a local hospital (Froedtert Memorial Lutheran Hospital, Milwaukee, WI, USA). The primary outcomes assessed were the incidence of hospital discharges with codes for heparin-induced thrombocytopenia and of discharges for heparin-induced thrombocytopenia associated with cardiopulmonary bypass, haemodialysis, hip or knee arthroplasty, trauma or injury (or both), and gingival or periodontal disease (or both). We also assessed the incidence of thrombosis, bleeding, limb or digit amputation, mortality, length of hospital stay, and associated hospital charges. FINDINGS Between 2009 and 2013, 97 566 discharges from the NIS assigned the ICD-9-CM code for heparin-induced thrombocytopenia, and 149 911 247 discharges coded for non-heparin-induced thrombocytopenia, were analysed. Overall, heparin-induced thrombocytopenia was identified in 97 566 (0·065%; SE 0·0012) of 150 008 813 discharges, corresponding to approximately one in 1500 hospital admissions. Patients undergoing cardiopulmonary bypass had the highest rates of heparin-induced thrombocytopenia (7702 [0·63%; SE 0·03] of 1 230 362), followed by those undergoing haemodialysis (23 012 [0·47%; 0·01] of 4 908 100), those with gingival or periodontal disease, or both (106 [0·12%; 0·03] of 88 621), and those with trauma or injury, or both (541 [0·09%; 0·01] of 602 944); patients with hip (845 [0·04%; 0·004] of 1 943 353) and knee (676 [0·02%; 0·002] of 3 022 602) arthroplasty had the lowest rates of heparin-induced thrombocytopenia. Thrombosis (29 079 [29·8%; SE 0·4] of 97 566) and bleeding (6044 [6·2%; 0·2] of 97 566) were common complications in heparin-induced thrombocytopenia, and 1446 (23·9%; 1·2) of 6044 patients with heparin-induced thrombocytopenia who had haemorrhage died. 742 (0·76%; SE 0·06) of 97 566 patients with heparin-induced thrombocytopenia discharges underwent amputations compared with 173 043 (0·12%; 0·001) of 149 911 247 with non-heparin-induced thrombocytopenia discharges (adjusted odds ratio 5·095 [95% CI 4·309-6·023]; p<0·0001). Overall, in-hospital mortality was 9842 (10·1%; SE 0·2) of 97 508 in discharge summaries coded for heparin-induced thrombocytopenia compared with 3 206 700 (2·1%; 0·01) of 149 811 891 in discharges for non-heparin-induced thrombocytopenia (adjusted odds ratio 4·075 [95% CI 3·846-4·317]; p<0·0001). The median length of stay among live discharges was 8·9 days (IQR 4·6-17·1) and total hospital charges were US$83 072 (IQR 37 240-188 419) for heparin-induced thrombocytopenia discharges compared with 2·6 days (1·4-4·8) and $21 360 (11 426-41 917) for non-heparin-induced thrombocytopenia discharges (p<0·0001 for both). 333 discharges from a local hospital were analysed to assess the diagnostic sensitivity and specificity of the heparin-induced thrombocytopenia ICD-9-CM code; sensitivity was 90·9% (95% CI 57·1-99·5) and specificity was 94·4% (91·1-96·6). INTERPRETATION Complication rates for heparin-induced thrombocytopenia remain high and more effective preventive and treatment interventions are needed. FUNDING None.
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Affiliation(s)
- Binod Dhakal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Baumann Kreuziger
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ariel Kleman
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Raphael Fraser
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard H Aster
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Parameswaran Hari
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anand Padmanabhan
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA; Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA.
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Rauova L, Arepally G, Poncz M, Cines DB. Molecular and cellular pathogenesis of heparin-induced thrombocytopenia (HIT). Autoimmun Rev 2018; 17:1046-1052. [PMID: 30103043 DOI: 10.1016/j.autrev.2018.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Lubica Rauova
- Division of Hematology, Department of Pediatrics, Childrens Hospital of Philadelphia, USA; Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, USA
| | - Gowthami Arepally
- Division of Hematology, Department of Medicine, Duke University School of Medicine, USA
| | - Mortimer Poncz
- Division of Hematology, Department of Pediatrics, Childrens Hospital of Philadelphia, USA; Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, USA
| | - Douglas B Cines
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, USA; Department of Medicine, University of Pennsylvania, Perelman School of Medicine, USA.
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Fathi M. Heparin-induced thrombocytopenia (HIT): Identification and treatment pathways. Glob Cardiol Sci Pract 2018; 2018:15. [PMID: 30083545 PMCID: PMC6062760 DOI: 10.21542/gcsp.2018.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a major health problem, especially in cardiac surgery theaters, cardiac catheterization labs, and intensive care units. Some patients with HIT develop serious thrombotic complications like limb ischemia and gangrene, while others may not develop such complications and have only mild thrombocytopenia. Current laboratory diagnostic tools incur significant time delays before confirming HIT, therefore upon clinical suspicion, treatment of HIT should start immediately while awaiting laboratory results. This is a review of the types, phases, pathophysiology, clinical presentation and diagnosis of HIT, and its current management strategies.
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Effects of Natural Hirudin and Low Molecular Weight Heparin in Preventing Deep Venous Thrombosis in Aged Patients with Intertrochanteric Fracture. Sci Rep 2018; 8:8847. [PMID: 29891906 PMCID: PMC5995864 DOI: 10.1038/s41598-018-27243-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/29/2018] [Indexed: 02/05/2023] Open
Abstract
Our objective was to evaluate the efficacy and safety of natural hirudin and low molecular weight heparin (LMWH) in the prevention of perioperative deep venous thrombosis (DVT) in elderly patients with intertrochanteric fracture. From June 2014 to June 2017, 96 patients with intertrochanteric fractures were treated with proximal femoral nail antirotation (PFNA) were randomly divided into two groups. For DVT prevention, 45 patients were treated with oral natural hirudin and subcutaneous LMWH-calcium (test group) and 51 patients were treated with subcutaneous LMWH-calcium (control group). The mean intraoperative bleeding, wound drainage and incisional hematoma were higher in the test group, with no significant differences between the groups. There were significant differences in distal intramuscular venous thrombosis (P = 0.043). Both activated partial thromboplastin time (APTT), thrombin time (TT), and prothrombin time (PT) lengthened in both groups postoperatively, and there was a significant difference between the two groups two weeks postoperatively. D-dimer were significantly different and platelet count (PLT) did not differ between groups two weeks postoperatively. In elderly patients with unilateral intertrochanteric fracture after PFNA on anticoagulant therapy, the combination of natural hirudin and LMWH was more effective than that of LMWH-calcium alone, with no significant difference with regard to safety.
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East JM, Cserti-Gazdewich CM, Granton JT. Heparin-Induced Thrombocytopenia in the Critically Ill Patient. Chest 2017; 154:678-690. [PMID: 29253554 DOI: 10.1016/j.chest.2017.11.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 11/22/2017] [Accepted: 11/29/2017] [Indexed: 01/19/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is associated with clinically significant morbidity and mortality. Patients who are critically ill are commonly thrombocytopenic and exposed to heparin. Although HIT should be considered, it is not usually the cause of thrombocytopenia in the medical-surgical ICU population. A systematic approach to the patient who is critically ill who has thrombocytopenia according to clinical features, complemented by appropriate laboratory confirmation, should lead to a reduction in inappropriate laboratory testing and reduce the use of more expensive and less reliable anticoagulants. If the patient is deemed as being at intermediate or high risk for HIT or if HIT is confirmed by means of the serotonin-release assay, heparin should be stopped, heparin-bonded catheters should be removed, and a direct antithrombin or fondaparinux should be initiated to reduce the risk of thrombosis. Warfarin is absolutely contraindicated in the acute phase of HIT; if administered, its effects must be reversed by using vitamin K.
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Affiliation(s)
- James M East
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | - John T Granton
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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33
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Rice L. HITs and misses in 100 years of heparin. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:667-673. [PMID: 29222319 PMCID: PMC6142618 DOI: 10.1182/asheducation-2017.1.667] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Heparin was discovered 100 years ago, and the heparin-induced thrombocytopenia syndrome was described 40 years ago. That the most powerful anticoagulant of the last century can also produce the most extreme prothrombotic diathesis is but one of the paradoxes that surround heparin-induced thrombocytopenia. Standard treatment is alternative anticoagulation. Advances continue to be made regarding pathophysiology, prevention, and treatment. Currently, an epidemic of overdiagnosis threatens the well-being of patients, so efforts to educate clinicians on when and how to make this diagnosis are pressing.
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Affiliation(s)
- Lawrence Rice
- Hematology Division, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medical College, Houston, TX
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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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Salter BS, Weiner MM, Trinh MA, Heller J, Evans AS, Adams DH, Fischer GW. Heparin-Induced Thrombocytopenia: A Comprehensive Clinical Review. J Am Coll Cardiol 2017; 67:2519-32. [PMID: 27230048 DOI: 10.1016/j.jacc.2016.02.073] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/03/2016] [Accepted: 02/08/2016] [Indexed: 12/13/2022]
Abstract
Heparin-induced thrombocytopenia is a profoundly dangerous, potentially lethal, immunologically mediated adverse drug reaction to unfractionated heparin or, less commonly, to low-molecular weight heparin. In this comprehensive review, the authors highlight heparin-induced thrombocytopenia's risk factors, clinical presentation, pathophysiology, diagnostic principles, and treatment. The authors place special emphasis on the management of patients requiring procedures using cardiopulmonary bypass or interventions in the catheterization laboratory. Clinical vigilance of this disease process is important to ensure its recognition, diagnosis, and treatment. Misdiagnosis of the syndrome, as well as misunderstanding of the disease process, continues to contribute to its morbidity and mortality.
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Affiliation(s)
- Benjamin S Salter
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York.
| | - Menachem M Weiner
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - Muoi A Trinh
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - Joshua Heller
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - Adam S Evans
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - David H Adams
- Department of Cardiac Surgery, Mount Sinai Medical Center, New York, New York
| | - Gregory W Fischer
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
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Cardinale M, Ha M, Liu MH, Reardon DP. Direct Thrombin Inhibitor Resistance and Possible Mechanisms. Hosp Pharm 2016; 51:922-927. [PMID: 28057952 DOI: 10.1310/hpj5111-922] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Objective: To report 3 cases in which doses of bivalirudin higher than commonly used in clinical practice were required in order to achieve therapeutic anticoagulation as monitored by the activated partial thromboplastin time (aPTT). Case Summary: The medical records of 3 patients who required large doses of bivalirudin to remain therapeutic were thoroughly reviewed. In all 3 patients, bivalirudin was initiated at a rate appropriate for the patients' renal function and titrated using a nurse-driven protocol with recommended dose adjustments based on aPTT. Indications for bivalirudin were anticoagulation in intra-aortic balloon pump, treatment of deep vein thrombosis, and heparin-induced thrombocytopenia with thrombosis. Target aPTT was achieved between 25.5 and 134 hours after initiation despite appropriate titration intervals per protocol. Discussion: Bivalirudin is a direct thrombin inhibitor frequently used off-label for the medical management of heparin-induced thrombocytopenia. It typically exhibits predictable, dose-dependent anticoagulation. Heparin-induced thrombocytopenia was suspected in 2 of the 3 cases and confirmed in 1. In all 3 patients, target aPTT was initially achieved with doses between 0.456 and 1.0 mg/kg/h after a median of 30.7 hours; up to 1.8 mg/kg/h was required to maintain therapeutic aPTT. In 2 of the cases, the international normalized ratio also increased unexpectedly upon achievement of therapeutic aPTT values. Conclusion: Direct thrombin inhibitors may be subject to resistance mechanisms similar to those previously described in patients receiving heparin. The anticoagulation status of these patients remains unknown.
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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: 31] [Impact Index Per Article: 3.9] [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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Extracorporeal Life Support: Physiological Concepts and Clinical Outcomes. J Card Fail 2016; 23:181-196. [PMID: 27989868 DOI: 10.1016/j.cardfail.2016.10.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 10/09/2016] [Accepted: 10/24/2016] [Indexed: 11/23/2022]
Abstract
Extracorporeal life support (ECLS) describes a system that involves drainage from the venous circulation and return via an oxygenator into the arterial circulation (veno-arterial extracorporeal membrane oxygenation). ECLS provides effective cardiopulmonary support, but the parallel circulation has complex effects on the systemic and pulmonary circulatory physiology. An understanding of the physiological changes is fundamental to the management of ECLS. In this review, the key physiological concepts and the implications on the clinical management of ECLS are discussed. In addition, the clinical outcomes associated with ECLS in cardiogenic shock are systematically reviewed. The paucity of clinical trials on ECLS highlights the need for randomized trials to guide the selection of patients.
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Rollins AR, Smith KE, Zemrak WR. Implementation of a Simplistic Bivalirudin-Warfarin Transition Protocol Is Associated With Improved Achievement of INR Values Within the Therapeutic Range. Ann Pharmacother 2016; 50:1001-1008. [DOI: 10.1177/1060028016660989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Transition from bivalirudin to long-term warfarin therapy is often difficult to execute due to bivalirudin prolongation of the international normalized ratio (INR), and literature to help guide this transition is extremely limited. Objective: To assess the transition from bivalirudin to warfarin after implementation of an institution-wide transition protocol. Methods: In this retrospective quasiexperimental study, adult patients receiving bivalirudin directly followed by warfarin for nonprocedural systemic anticoagulation were evaluated to determine the frequency of successful transition to warfarin. Participants were compared before (preprotocol) and after (postprotocol) the implementation of the transition protocol. Results: A total of 39 patients met inclusion criteria and were included in the analysis (preprotocol = 19; postprotocol = 20). The percentage of patients achieving a successful transition was significantly higher in the postprotocol group compared with the preprotocol group (80.0% vs 42.1%, P = 0.015). Bleeding events were similar between the 2 groups (23.1% vs 16.7%, P = 0.689). Withholding of warfarin doses or the use of anticoagulant reversal agents or blood transfusions for supratherapeutic INR levels, surgical procedures, or drop in hemoglobin was numerically lower in the postprotocol group compared with the preprotocol group (16.7% vs 46.2%, P = 0.202). Conclusion: Implementation of a simplistic bivalirudin-warfarin transition protocol significantly increased the frequency of therapeutic INR results on bivalirudin discontinuation. Additionally, patients treated according to this protocol were less likely to have warfarin doses withheld or require reversal agents. Larger studies testing this transition strategy are warranted.
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Affiliation(s)
| | - Kathryn E. Smith
- Maine Medical Center, Portland, ME, USA
- Tufts University, Boston, MA, USA
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40
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Arangalage D, Lepage L, Faille D, Cimadevilla C, Dilly MP, Papy E, Alhenc-Gelas M, Ghodbane W, Nataf P, Iung B, Steg PG, Vahanian A, Ajzenberg N, Messika-Zeitoun D. Presentation, management and outcome of heparin-induced thrombocytopenia after valvular heart surgery. Eur J Cardiothorac Surg 2016; 50:1132-1138. [PMID: 27301386 DOI: 10.1093/ejcts/ezw200] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 05/01/2016] [Accepted: 05/04/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The use of heparin exposes patients to heparin-induced thrombocytopenia, which is a challenging issue for both diagnosis and patient management. We sought to describe the clinical presentation, management and outcome of a series of patients diagnosed with heparin-induced thrombocytopenia after heart valve surgery. METHODS All consecutive patients diagnosed with heparin-induced thrombocytopenia during the postoperative period of heart valve surgery over a 6-year period were prospectively enrolled in a single-centre registry. Clinical and biological data were collected. In-hospital and mid-term outcomes were assessed. Information regarding the occurrence of all medical events including death, recurrence of thromboembolic events and/or thrombocytopenia was collected. RESULTS We identified 93 patients (incidence proportion = 2.8%). Most patients (82%) were asymptomatic with isolated thrombocytopenia at the time of diagnosis. The other main circumstance of diagnosis was the occurrence of thromboembolic events in 17 patients (6 strokes, 10 prosthetic valve thrombosis and 1 peripheral embolic event). The in-hospital mortality rate was 1%. No thrombolysis, interventional procedure or redo surgery was performed. Danaparoid sodium was used as heparin replacement therapy in most cases (96%) and leading to complete and uneventful thrombus resolution in all cases with only one possibly related major bleeding complication. During a mean follow-up of 36 ± 20 months, no patient presented recurrence of any heparin-induced thrombocytopenia-related complication. CONCLUSIONS In this contemporary series of patients, heparin-induced thrombocytopenia incidence was low and isolated thrombocytopenia was the most frequent presentation. Conservative management with early diagnosis and substitutive anticoagulation therapy introduction was associated with a low rate of clinical events and a remarkably good outcome with a low mortality rate.
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Affiliation(s)
- Dimitri Arangalage
- Department of Cardiology, Bichat Hospital, Paris, France.,INSERM U1148, Bichat Hospital, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Faculté de Médecine Paris-Diderot, Paris, France
| | - Laurent Lepage
- Department of Cardiac Surgery, Bichat Hospital, Paris, France
| | - Dorothée Faille
- INSERM U1148, Bichat Hospital, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Faculté de Médecine Paris-Diderot, Paris, France.,Department of Hematology, Bichat Hospital, Paris, France
| | | | | | | | - Martine Alhenc-Gelas
- Department of Biological Hematology, European Hospital Georges Pompidou, AP-HP, Paris, France
| | - Walid Ghodbane
- Department of Cardiac Surgery, Bichat Hospital, Paris, France
| | - Patrick Nataf
- INSERM U1148, Bichat Hospital, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Faculté de Médecine Paris-Diderot, Paris, France.,Department of Cardiac Surgery, Bichat Hospital, Paris, France
| | - Bernard Iung
- Department of Cardiology, Bichat Hospital, Paris, France.,INSERM U1148, Bichat Hospital, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Faculté de Médecine Paris-Diderot, Paris, France
| | - Philippe Gabriel Steg
- Department of Cardiology, Bichat Hospital, Paris, France.,INSERM U1148, Bichat Hospital, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Faculté de Médecine Paris-Diderot, Paris, France
| | - Alec Vahanian
- Department of Cardiology, Bichat Hospital, Paris, France.,INSERM U1148, Bichat Hospital, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Faculté de Médecine Paris-Diderot, Paris, France
| | - Nadine Ajzenberg
- INSERM U1148, Bichat Hospital, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Faculté de Médecine Paris-Diderot, Paris, France.,Department of Hematology, Bichat Hospital, Paris, France
| | - David Messika-Zeitoun
- Department of Cardiology, Bichat Hospital, Paris, France .,INSERM U1148, Bichat Hospital, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Faculté de Médecine Paris-Diderot, Paris, France
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41
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Scully M, Gates C, Neave L. How we manage patients with heparin induced thrombocytopenia. Br J Haematol 2016; 174:9-15. [PMID: 27097741 DOI: 10.1111/bjh.14102] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Heparin induced thrombocytopenia (HIT) remains a rare, but significant, condition related to mortality and morbidity. The incidence has decreased with reduced use of unfractionated heparin, with the exception of cardiac surgery. Due to the high risk of thrombosis, a switch to a non-heparin anticoagulant is required, until platelet counts normalize. Within the acute setting, argatroban, fondaparinux and direct acting oral anticoagulants (DOACS) are therapeutic options. In patients with HIT-associated thrombosis or who require long-term anticoagulation, warfarin remains the preference, but DOACs are attractive alternatives.
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Affiliation(s)
- Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, UK
| | - Carolyn Gates
- Thrombosis and Anticoagulant Pharmacist, University College London Hospital, London, UK
| | - Lucy Neave
- Specialist Registrar, Department of Haematology, UCLH, London, UK
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42
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Cuker A. Management of the multiple phases of heparin-induced thrombocytopenia. Thromb Haemost 2016; 116:835-842. [PMID: 27075525 DOI: 10.1160/th16-02-0084] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/27/2016] [Indexed: 01/01/2023]
Abstract
The clinical course of heparin-induced thrombocytopenia (HIT) may be separated into five sequential phases: 1. suspected HIT, 2. acute HIT, 3. subacute HIT A, 4. subacute HIT B, and 5. remote HIT. Each phase confronts the clinician with a unique set of management questions. In this review, the phases of HIT are defined and key management questions associated with each phase are discussed. Among patients with Suspected HIT, I use the 4Ts score to determine which patients have a sufficiently high probability of HIT to justify discontinuation of heparin and initiation of a non-heparin parenteral anticoagulant. An algorithm for selecting an appropriate non-heparin anticoagulant based on the patient's clinical stability, renal and hepatic function, drug availability, and physician comfort is provided. In patients with Acute HIT, I generally avoid prophylactic platelet transfusion and inferior vena cava filter insertion because of a potential increased risk of thrombosis. I perform 4-limb screening compression ultrasonography. In patients with symptomatic thromboembolism or asymptomatic proximal deep-vein thrombosis, I treat with anticoagulation for three months. In patients without thrombosis, I discontinue anticoagulation upon platelet count recovery. I do not transition patients to an oral anticoagulant until platelet count recovery (i. e. Subacute HIT A). I increasingly choose direct oral anticoagulants over vitamin K antagonists in this setting because of their greater convenience and safety. In Subacute HIT B and Remote HIT, I use heparin for cardiovascular surgery, whereas I use bivalirudin in patients with Acute HIT and Subacute HIT A in whom surgery cannot be delayed.
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Affiliation(s)
- Adam Cuker
- Adam Cuker, MD, MS, Penn Comprehensive Hemophilia and Thrombosis Program, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA, Tel.: +1 215 615 6555, Fax: +1 215 615 6599, E-mail:
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43
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Al-Ali FS, Elsayed M, Khalifa S, Abdulla AE, Tolba H, Bouanane H, Ibrahim R, Hamad A. Successful use of a bivalirudin treatment protocol to prevent extracorporeal thrombosis in ambulatory hemodialysis patients with heparin-induced thrombocytopenia. Hemodial Int 2015; 20:204-7. [PMID: 26501237 DOI: 10.1111/hdi.12379] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is an uncommon problem in hemodialysis (HD) patients. There have been a few reports on the use of lepirudin, argatroban, or danaparoid in the management of extracorporeal thrombosis (ECT) during dialysis in these patients, because heparin is contraindicated. Here, we report the first long-term use of bivalirudin to prevent ECT. Our study was conducted at Fahd Bin Jassim Kidney Center in Doha, Qatar. All patients diagnosed with HIT were included. A bivalirudin treatment protocol was developed with the initial dosage and dosage adjustments based on the value of activated partial thromboplastin time (aPTT), the risk of bleeding, and the recurrence of ECT. Eight patients were positive for HIT AB. Among them, three were excluded: two due to the use of warfarin for atrial fibrillation and one due to a negative repeat HIT AB test with no ECT. Five patients who were positive for HIT AB and experienced recurrent ECT events during dialysis were included. These patients were monitored while on bivalirudin protocol for a mean of 4.6 ± 2 months, during which they received a mean number of HD treatments of 66 ± 24. There were no bleeding events or adverse reactions related to bivalirudin during the study. Here, we report the first long-term successful use of a bivalirudin protocol to prevent ECT in ambulatory HD patients with HIT. This protocol allowed for a simple dosing initiation with easy adjustment based on weight, aPTT, and recurrence of ECT events. The protocol provided excellent safety.
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Affiliation(s)
- Fadwa Saqr Al-Ali
- Division of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
| | - Mohammed Elsayed
- Division of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
| | - Sabah Khalifa
- Division of Pharmacology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
| | - Aisha Elsayed Abdulla
- Division of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
| | - Hoda Tolba
- Division of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
| | - Hisham Bouanane
- Division of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
| | - Rania Ibrahim
- Division of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
| | - Abdullah Hamad
- Division of Nephrology, Fahad Bin Jassim Kidney Center, Hamad General Hospital, Doha, Qatar
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44
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Sanidas EA, Viniou NA, Diamantopoulos P, Barbetseas J. Heparin induced thrombocytopenia. Contemporary therapeutic approaches in light of the new oral anticoagulants. Hamostaseologie 2015; 35:372-5. [PMID: 26302031 DOI: 10.5482/hamo-15-04-0013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/12/2015] [Indexed: 12/12/2022] Open
Abstract
Heparin induced thrombocytopenia (HIT) is a prothrombotic syndrome initiated by platelet-activating auto-antibodies with potentially devastating complications. Once the diagnosis of HIT is suspected, discontinuation of heparin and treatment with an alternative anticoagulant are mandatory. While established drugs for HIT are no longer available, parenteral factor Xa inhibitors, thrombin inhibitors and perhaps the direct oral anticoagulants provide additional treatment options. The aim of this review was to highlight the current clinical aspects regarding HIT focusing on the role of novel medications.
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Affiliation(s)
- E A Sanidas
- Elias Sanidas MD, PhD, FACC, FESC, Department of Cardiology, Laiko General Hospital, 17 Agiou Thoma street, 11527, Athens, Greece,
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