Eptifibatide-induced acute profound thrombocytopenia: a case report

Delayed-onset eptifibatide-induced thrombocytopenia

PURPOSE

We present a unique case of delayed-onset, profound eptifibatide-induced thrombocytopenia that occurred 5 days after initiation of the drug.

SUMMARY

Eptifibatide is a platelet glycoprotein IIb/IIIa receptor inhibitor with indications for use in patients with acute coronary syndromes. Eptifibatide-induced thrombocytopenia is uncommon but well studied and typically occurs within 24 hours of initiation of the drug. In the case described here, a 62-year-old male with a past history of coronary artery disease (including percutaneous coronary intervention within the past 12 months) was started on eptifibatide at a dosage of 2 µg/kg per minute for management of significant thrombus burden prior to a planned cardiac revascularization procedure; heparin for anticoagulation was also initiated. About 5 days after initiation of eptifibatide, the patient developed severe thrombocytopenia, with the platelet count dropping precipitously from 249 × 103/µL on admission to less than 1 × 103/µL. After eptifibatide and heparin therapy were discontinued and the patient was switched to argatroban, the platelet count recovered to 38 × 103/µL over the next 2 days. An eptifibatide platelet antibody assay was positive for IgG-mediated reactions consistent with eptifibatide-induced thrombocytopenia. Scoring of this case with the Naranjo scale yielded a score of 4, suggesting a possible adverse reaction to eptifibatide.

CONCLUSION

This is the first published case report of profound eptifibatide-induced thrombocytopenia occurring more than 24 hours after eptifibatide initiation and serves to bring awareness that a delayed reaction can occur.

Eptifibatide-induced acute profound thrombocytopenia: A case report

RATIONALE

Eptifibatide is an antiplatelet agent used in the medical management of acute coronary syndrome. Although multiple studies did not reveal a significant association between eptifibatide and the development of thrombocytopenia, recent case reports brought attention to this relatively rare side effect.

PATIENT CONCERNS

We report a 61 years old male with acute coronary syndrome who underwent primary coronary intervention.

DIAGNOSIS AND INTERVENTION

The patient developed acute profound thrombocytopenia following eptifibatide administration. Following prompt offending drug discontinuation, the platelet counts recovered, without clinical sequelae or the need for platelet transfusion. Dual antiplatelet therapy with aspirin and clopidogrel was resumed after platelet count normalization.

OUTCOMES

The patient had a normal platelet count and no bleeding events on follow-up after three months upon discharge.

CONCLUSION

Eptifibatide, a glycoprotein IIa/IIIb inhibitor used in the management of acute coronary syndrome, can induce acute, profound thrombocytopenia that can have significant morbidity in patients. This case highlights this relatively rare side effect and the importance of monitoring blood counts and observing for any signs of bleeding or thrombosis that might occur in such patients.

Safety, pharmacokinetics and pharmacodynamics of an original glycoprotein IIb/IIIa inhibitor in healthy volunteers: results of the clinical trial

Aim. To study the tolerability, safety, pharmacokinetics (PK) and pharmacodynamics of single intravenous infusions of Angipur in healthy male volunteers.

Material and methods. The Phase I trial included 20 healthy male volunteers (mean age, 30,8±7,7 years; mean body weight, 77,4±12,1 kg). Angipur (0,02% concentrate for solution for infusion) was administered to every subject in single doses 0,015, 0,05, 0,09 mg/kg for 3 consecutive days. Volunteers were divided in 6 groups (1, 1, 3, 5, 5, 5); every following group was recruited only after the previous one finished the study. The following were assessed: rate and severity of adverse events (AEs), key PK parameters of Angipur and its antiplatelet activity by impedance aggregometry.

Results. No moderate or severe AEs, as well as no serious AEs were reported according to obtained data of clinical and laboratory monitoring of healthy subjects. Totally 6 mild AEs were registered in 4 subjects. Four AEs (mild hematological deviations and episode of nose bleed) were classified as possibly related to study drug and 1 AE (positive fecal occult blood test)  — probably related. Key PK parameters of Angipur in single intravenous doses 0,015, 0,05 и  0,09 mg/kg were determined as follows: Cmax — 12,44±4,689, 46,10±14,295, 92,48±33,896 ng/ml; Vd  — 304,01±55,300, 299,67±64,244, 252,96±47,790 l; T1/2  — 6,72±1,290, 6,84±2,341, 6,06±2,287 h; Cl  — 32,19±6,919, 32,29±8,357, 31,55±10,113 l/h, respectively. Dose proportionality (linear PK) for parameters Cmax, AUC0-t and AUC0-∞ was established. Dose-dependent reduction of ADP-induced platelet aggregation degree and area under curve was revealed at period of 15 min to 2-4 h after Angipur infusion in doses 0,05 and 0,09 mg/kg.

Conclusion. Results of phase I clinical trial demonstrated good tolerability of single intravenous infusions of Angipur (0,015, 0,05 и 0,09 mg/kg) in healthy subjects. We determined key PK parameters and indicated dose-dependent antiplatelet activity of Angipur.

Acute Profound Thrombocytopenia Induced by Eptifibatide Causing Diffuse Alveolar Hemorrhage

Background

Eptifibatide is a glycoprotein IIb/IIIa (GP IIb/IIIa) receptor inhibitor which prevents platelet activation. The mechanism in which eptifibatide causes profound thrombocytopenia is poorly understood. One hypothesis suggests antibody-dependent pathways which cause thrombocytopenia upon subsequent reexposure to eptifibatide. This case reports acute profound thrombocytopenia (platelets < 20 × 10³/mm³) within 24 hours of administration. Alveolar hemorrhage occurred during a second eptifibatide infusion 5 days after initial asymptomatic eptifibatide treatment. Case Presentation. A 50-year-old male presenting with a STEMI was treated with eptifibatide during cardiac catheterization. Twelve hours posttreatment, the patient encountered profound thrombocytopenia and hemoptysis. The patient was briefly intubated for airway protection. The patient was stabilized after receiving platelet transfusion and fully recovered.

Conclusion

This is one of several cases reported on eptifibatide causing acute profound thrombocytopenia and subsequent alveolar hemorrhage. This case supports the theory in which antibodies contribute to eptifibatide-induced thrombocytopenia.

Eptifibatide-induced profound thrombocytopaenia: a rare complication

Drug-induced immune thrombocytopaenia (DITP) is a type of thrombocytopaenia caused by medications. It is one of the common causes of unexplained thrombocytopaenia. It is caused by the formation of autoantibodies against a particular drug and is commonly observed with medications like heparin and beta-lactam antibiotics. One of the rare causes of DITP is eptifibatide, a widely used antiplatelet agent for pretreatment in cardiac catheterisation. These patients can be asymptomatic or develop complications like skin bruising, epistaxis and even intracranial haemorrhage. We present a case of a 64-year-old man who developed eptifibatide-induced profound thrombocytopaenia leading to extensive skin bruising. He was treated with platelet transfusions followed by prompt improvement in platelet count.

Complications and Management of Eptifibatide-Induced Thrombocytopenia

BACKGROUND

Eptifibatide is used in acute coronary syndromes to reversibly block platelet aggregation by inhibiting the platelet glycoprotein IIb/IIIa receptor. A serious adverse effect of eptifibatide is a profound drop in platelet count, termed eptifibatide-induced thrombocytopenia (EIT).

OBJECTIVE

To provide insight into the types of complications and management of EIT.

METHODS

Cases of EIT submitted to the Food and Drug Administration adverse event reporting system were evaluated. Data analyses included management of EIT, complications of thrombocytopenia, initial platelets, and platelet nadir following eptifibatide.

RESULTS

103 cases of EIT were reported from January 2010 to 2019; 57 cases met the Naranjo scale and were included. Only 37 of those cases contained information on how EIT was managed. Eptifibatide administration was withheld in all 37 of those cases. Platelet transfusions were administered in 20 cases (54%). Two cases were managed with steroids (5.4%), and 1 case used intravenous immunoglobulin G to reverse EIT (2%). The median initial platelet count prior to administration of eptifibatide was 207 000 cells/mm³ (SD = 69 000; n = 27), and median platelet nadir was 9000 cells/mm³ (SD = 19 000; n = 35) The majority of complications of EIT included bleeding events (16/28, 57%). Delayed procedures, prolonged stay, allergic reactions, and thrombosis were each reported in 3 patients (10.75%).

CONCLUSION AND RELEVANCE

Most cases of EIT were managed by withholding eptifibatide with platelet transfusion if necessary. The majority of complications included bleeding. However, significant procedure delays, prolonged hospital stay, thrombosis, and allergic reactions were also reported.

Eptifibatide-Induced Profound Thrombocytopenia After Percutaneous Intervention for Acute Coronary Syndrome: A Challenging Clinical Scenario

Eptifibatide is a glycoprotein (GP) IIb/IIIa inhibitor used mostly in the treatment of acute coronary syndrome (ACS). The GP IIb/IIIa antagonists occupy the fibrinogen binding site at the GP IIb/IIIa and block thrombocyte aggregation independent of the initial activation pathway. Severe thrombocytopenia has been reported with eptifibatide use. Thrombocytopenia after ACS can have multiple etiologies. Human immunodeficiency virus (HIV) infection has also been implicated in immune-mediated thrombocytopenia. In this manuscript, we report a case of acute severe thrombocytopenia secondary to eptifibatide use in a patient with a history of HIV infection who presented with an ST elevation myocardial infarction. We also review the differential diagnosis and suggest management strategies in this challenging clinical scenario.

A Case of Hyperacute Severe Thrombocytopenia Occurring Less than 24 Hours after Intravenous Tirofiban Infusion

Thrombocytopenia is defined as a condition where the platelet count is below the lower limit of normal (<150 G/L), and it is categorized as mild (100–149 G/L), moderate (50–99 G/L), and severe (<50 G/L). We present here a 79-year-old man who developed severe thrombocytopenia with a platelet count of 6 G/L, less than 24 hours after intravenous tirofiban infusion that was given to the patient during a percutaneous transluminal coronary angioplasty procedure with placement of 3 drug-eluting stents. The patient's baseline platelet count was 233 G/L before the procedure. Based on the timeline of events during hospitalization and laboratory evidence, it was highly likely that the patient's thrombocytopenia was the result of tirofiban-induced immune thrombocytopenia, a type of drug-induced immune thrombocytopenia (DITP) which occurs due to drug-dependent antibody-mediated platelet destruction. Anticoagulant-mediated artefactual pseudothrombocytopenia was ruled out as no platelet clumping was seen on the peripheral blood smears. The treatment of DITP includes discontinuation of the causative drug; monitoring of platelet count recovery; or treatment of severe thrombocytopenia with glucocorticoids, IVIG, or platelet transfusions depending on the clinical presentation. The most likely causative agent of this patient's thrombocytopenia—tirofiban—was discontinued, and the patient did not develop any signs of bleeding during the remainder of his hospital stay. His platelet count gradually improved to 24 G/L, and he was discharged on the sixth hospital day.