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Mayerhöfer T, Joannidis M, Peer A, Perschinka F, Fries D, Mair P, Gasteiger L, Bachler M, Kilo J, Herkner H, Schwameis M, Schellongowski P, Nagler B, Kornfehl A, Staudinger T, Buchtele N. Anticoagulation with argatroban using hemoclot™ targets is safe and effective in CARDS patients receiving venovenous extracorporeal membrane oxygenation: An exploratory bi-centric cohort study. Thromb Res 2024; 236:161-166. [PMID: 38452448 DOI: 10.1016/j.thromres.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/19/2024] [Accepted: 02/24/2024] [Indexed: 03/09/2024]
Abstract
Direct thrombin inhibitors, including argatroban, are increasingly used for anticoagulation during venovenous extracorporeal membrane oxygenation (VV ECMO). In many centers activated partial thromboplastin time (aPTT) is used for monitoring, but it can be affected by several confounders. The aim of this study was to evaluate the safety and efficacy of anticoagulation with argatroban titrated according to diluted thrombin time targets (hemoclot™ assay) compared to anti-Xa guided anticoagulation with unfractionated heparin (UFH). METHODS This cohort study included adults at two tertiary care centers who required VV ECMO for severe COVID-19-related acute respiratory distress syndrome (CARDS). Patients received center-dependent argatroban or UFH for anticoagulation during ECMO. Argatroban was guided following a hemoclot™ target range of 0.4-0.6 μg/ml. UFH was guided by anti-factor Xa (antiXa) levels (0.2-0.3 IU/ml). The primary outcome was safety of argatroban compared to UFH, assessed by time to first clinically relevant bleeding event or death during ECMO. Secondary outcomes included efficacy (time to thromboembolism) and feasibility (proportion of anticoagulation targets within range). RESULTS From 2019 to 2021 57 patients were included in the study with 27 patients (47 %) receiving argatroban and 30 patients (53 %) receiving UFH. The time to the first clinically relevant bleeding or death during ECMO was similar between groups (HR (argatroban vs. UFH): 1.012, 95 % CI 0.44-2.35, p = 0.978). Argatroban was associated with a decreased risk for thromboembolism compared to UFH (HR 0.494 (95 % CI 0.26-0.95; p = 0.034)). The overall proportion of anticoagulation within target ranges was not different between groups (46 % (23-54 %) vs. 46 % (37 %-57 %), p = 0.45). CONCLUSION Anticoagulation with argatroban according to hemoclot™ targets (0.4-0.6 μg/ml) compared to antiXa guided UFH (0.2-0.3 IU/ml) is safe and may prolong thromboembolism-free time in patients with severe ARDS requiring VV ECMO.
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Affiliation(s)
- Timo Mayerhöfer
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Andreas Peer
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Fabian Perschinka
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Dietmar Fries
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Peter Mair
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Mirjam Bachler
- Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), UMIT - Private University for Health Sciences and Health Technology, Hall i.T., Austria
| | - Juliane Kilo
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria
| | - Bernhard Nagler
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria
| | - Andrea Kornfehl
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria
| | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria
| | - Nina Buchtele
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria.
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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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Menninger L, Körner A, Mirakaj V, Heck-Swain KL, Haeberle HA, Althaus K, Baumgaertner M, Jost W, Schlensak C, Rosenberger P, Koeppen M. Membrane oxygenator longevity was higher in argatroban-treated patients undergoing vvECMO. Eur J Clin Invest 2023; 53:e13963. [PMID: 36718989 DOI: 10.1111/eci.13963] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/23/2023] [Accepted: 01/28/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND In severe acute respiratory distress syndrome (ARDS), venovenous extracorporeal membrane oxygenation (vvECMO) can be a lifesaver. However, anticoagulation therapy is mandatory because the nonendothelial extracorporeal surface increases the risk of thromboembolic problems. Heparin is still the most common anticoagulant, but argatroban could be an alternative. This work investigates whether argatroban offers a therapeutic advantage over heparin during vvECMO. METHODS We performed a retrospective cohort study of patients who underwent vvECMO for severe ARDS and received heparin or argatroban as anticoagulation therapy. Demographic variables, intensive care unit (ICU) treatment and outcome parameters were evaluated. The primary outcome parameter was the operating time of the membrane oxygenator normalized to the duration of vvECMO treatment. Secondary outcome parameters were transfusion requirements normalized to the duration of vvECMO therapy. RESULTS Fifty seven patients from January 2019 to February 2021 underwent vvECMO and were included in this study. Thirty three patients received heparin and 24 patients argatroban as anticoagulatory therapy. The groups did not differ in demographics, ICU scoring systems, or comorbidities. Platelet counts and partial prothrombin time did not differ between the two groups during the first 6 days of vvECMO. The argatroban group had lower requirements for red blood cells, platelets and fresh frozen plasma. The mean runtime of the individual membrane oxygenator increased from 12.3 days (heparin group) to 16.6 days in the argatroban group. CONCLUSIONS Our findings suggest that argatroban can be considered as anticoagulant during vvECMO.
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Affiliation(s)
- Loredana Menninger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Andreas Körner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Valbona Mirakaj
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Ka-Lin Heck-Swain
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Helene A Haeberle
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Karina Althaus
- Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tübingen, Germany
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Michael Baumgaertner
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Walter Jost
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Michael Koeppen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
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Zeibi Shirejini S, Carberry J, McQuilten ZK, Burrell AJC, Gregory SD, Hagemeyer CE. Current and future strategies to monitor and manage coagulation in ECMO patients. Thromb J 2023; 21:11. [PMID: 36703184 PMCID: PMC9878987 DOI: 10.1186/s12959-023-00452-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/18/2023] [Indexed: 01/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) can provide life-saving support for critically ill patients suffering severe respiratory and/or cardiac failure. However, thrombosis and bleeding remain common and complex problems to manage. Key causes of thrombosis in ECMO patients include blood contact to pro-thrombotic and non-physiological surfaces, as well as high shearing forces in the pump and membrane oxygenator. On the other hand, adverse effects of anticoagulant, thrombocytopenia, platelet dysfunction, acquired von Willebrand syndrome, and hyperfibrinolysis are all established as causes of bleeding. Finding safe and effective anticoagulants that balance thrombosis and bleeding risk remains challenging. This review highlights commonly used anticoagulants in ECMO, including their mechanism of action, monitoring methods, strengths and limitations. It further elaborates on existing anticoagulant monitoring strategies, indicating their target range, benefits and drawbacks. Finally, it introduces several highly novel approaches to real-time anticoagulation monitoring methods including sound, optical, fluorescent, and electrical measurement as well as their working principles and future directions for research.
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Affiliation(s)
- Saeedreza Zeibi Shirejini
- grid.1002.30000 0004 1936 7857NanoBiotechnology Laboratory, Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Josie Carberry
- grid.1002.30000 0004 1936 7857Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Zoe K. McQuilten
- grid.1002.30000 0004 1936 7857Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, and Department of Clinical Haematology, Monash Health, Melbourne, VIC Australia
| | - Aidan J. C. Burrell
- grid.1623.60000 0004 0432 511XSchool of Medicine, Nursing, and Health Sciences, Clayton and Intensive Care Unit, Monash University, Alfred Hospital, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, VIC Australia
| | - Shaun D. Gregory
- grid.1002.30000 0004 1936 7857Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Christoph E. Hagemeyer
- grid.1002.30000 0004 1936 7857NanoBiotechnology Laboratory, Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC Australia
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Abstract
During sepsis, an initial prothrombotic shift takes place, in which coagulatory acute-phase proteins are increased, while anticoagulatory factors and platelet count decrease. Further on, the fibrinolytic system becomes impaired, which contributes to disease severity. At a later stage in sepsis, coagulation factors may become depleted, and sepsis patients may shift into a hypo-coagulable state with an increased bleeding risk. During the pro-coagulatory shift, critically ill patients have an increased thrombosis risk that ranges from developing micro-thromboses that impair organ function to life-threatening thromboembolic events. Here, thrombin plays a key role in coagulation as well as in inflammation. For thromboprophylaxis, low molecular weight heparins (LMWH) and unfractionated heparins (UFHs) are recommended. Nevertheless, there are conditions such as heparin resistance or heparin-induced thrombocytopenia (HIT), wherein heparin becomes ineffective or even puts the patient at an increased prothrombotic risk. In these cases, argatroban, a direct thrombin inhibitor (DTI), might be a potential alternative anticoagulatory strategy. Yet, caution is advised with regard to dosing of argatroban especially in sepsis. Therefore, the starting dose of argatroban is recommended to be low and should be titrated to the targeted anticoagulation level and be closely monitored in the further course of treatment. The authors of this review recommend using DTIs such as argatroban as an alternative anticoagulant in critically ill patients suffering from sepsis or COVID-19 with suspected or confirmed HIT, HIT-like conditions, impaired fibrinolysis, in patients on extracorporeal circuits and patients with heparin resistance, when closely monitored.
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6
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Warkentin TE. How to dose and monitor argatroban for treatment of HIT. Br J Haematol 2022; 197:653-655. [PMID: 35405030 DOI: 10.1111/bjh.18153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Abstract
Dosing and monitoring of argatroban for treatment of heparin-induced thrombocytopenia (HIT) remain uncertain. Marchetti and colleagues critically and systematically reviewed their institutional experience using this direct thrombin inhibitor to treat patients with laboratory-confirmed HIT, and have formulated several practical recommendations for managing this challenging clinical situation. Commentary on: Marchetti et al. Managing argatroban in heparin-induced thrombocytopenia: A retrospective analysis of 729 treatment days in 32 patients with confirmed heparin-induced thrombocytopenia. Br J Haematol. 2022 (Online ahead of print). https://doi.org/10.1111/bjh.18120.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine (Division of Transfusion Medicine) and Department of Medicine (Division of Hematology and Thromboembolism), McMaster University, Hamilton, Ontario, Canada
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Marchetti M, Barelli S, Gleich T, Gomez FJ, Goodyer M, Grandoni F, Alberio L. Managing argatroban in heparin-induced thrombocytopenia: A retrospective analysis of 729 treatment days in 32 patients with confirmed heparin-induced thrombocytopenia. Br J Haematol 2022; 197:766-790. [PMID: 35358358 PMCID: PMC9324832 DOI: 10.1111/bjh.18120] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Matteo Marchetti
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, UNIL, University of Lausanne, Lausanne, Switzerland
| | - Stefano Barelli
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Tobias Gleich
- Division of Transfusion Medicine and Immunohematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Francisco J Gomez
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Matthew Goodyer
- Division of Hematology and Laboratory of Hematology, Institut Central des Hôpitaux Valaisans, Sion, Switzerland
| | - Francesco Grandoni
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, UNIL, University of Lausanne, Lausanne, Switzerland
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8
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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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Guy S, Kitchen S, Makris M, M Maclean R, Saccullo G, Vanveen JJ. Caution in Using the Activated Partial Thromboplastin Time to Monitor Argatroban in COVID-19 and Vaccine-Induced Immune Thrombocytopenia and Thrombosis (VITT). Clin Appl Thromb Hemost 2021; 27:10760296211066945. [PMID: 34905962 PMCID: PMC8689594 DOI: 10.1177/10760296211066945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Argatroban is licensed for patients with heparin-induced thrombocytopenia and is conventionally monitored by activated partial thromboplastin time (APTT) ratio. The target range is 1.5 to 3.0 times the patients’ baseline APTT and not exceeding 100 s, however this baseline is not always known. APTT is known to plateau at higher levels of argatroban, and is influenced by coagulopathies, lupus anticoagulant and raised FVIII levels. It has been used as a treatment for COVID-19 and Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT). Some recent publications have favored the use of anti-IIa methods to determine the plasma drug concentration of argatroban. Methods Plasma of 60 samples from 3 COVID-19 patients and 54 samples from 5 VITT patients were tested by APTT ratio and anti-IIa method (dilute thrombin time dTT). Actin FS APTT ratios were derived from the baseline APTT of the patient and the mean normal APTT. Results Mean APTT ratio derived from baseline was 1.71 (COVID-19), 1.33 (VITT) compared to APTT ratio by mean normal 1.65 (COVID-19), 1.48 (VITT). dTT mean concentration was 0.64 µg/ml (COVID-19) 0.53 µg/ml (VITT) with poor correlations to COVID-19 baseline APTT ratio r2 = 0.1526 p <0.0001, mean normal r2 = 0.2188 p < 0.0001; VITT baseline APTT ratio r2 = 0.04 p < 0.001, VITT mean normal r2 = 0.0064 p < 0.001. Conclusions We believe that dTT is a superior method to monitor the concentration of argatroban, we have demonstrated significant differences between APTT ratios and dTT levels, which could have clinical impact. This is especially so in COVID-19 and VITT.
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Affiliation(s)
- Susan Guy
- 414090Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Steve Kitchen
- 414090Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Michael Makris
- 414090Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK.,152809The University of Sheffield Department of Infection Immunity and Cardiovascular Disease, Sheffield, UK
| | - Rhona M Maclean
- 414090Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Giorgia Saccullo
- 414090Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Joost J Vanveen
- 414090Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
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10
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Guy S, Kitchen S, Hopkins B, Chunara Z, Stephenson-Brown A, van Veen JJ. Laboratory methods for monitoring argatroban in heparin-induced thrombocytopenia. Int J Lab Hematol 2021; 44:399-406. [PMID: 34755452 DOI: 10.1111/ijlh.13757] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/13/2021] [Accepted: 10/20/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The Summary of Product Characteristics for the direct thrombin inhibitor argatroban states monitoring should be by activated partial thromboplastin time (APTT), with a target range of 1.5-3.0 times the patients' baseline APTT. APTT may be influenced by coagulopathies, lupus anticoagulant and raised FVIII levels. Previous studies have shown sensitivity differences of APTT reagents to argatroban. Some recent publications have favoured the use of anti-IIa methods to determine the plasma drug concentration of argatroban. This study aims to compare the anti-IIa assays: Hemoclot thrombin inhibitor assay (HTI) and Ecarin chromogenic assay (ECA) alongside the APTT. METHODS Residual plasma of 25 samples from 8 patients (3 with COVID-19 and HIT: n = 18, 5 with HIT: n = 7) was tested at two sites: site A: Sysmex CS5100 by HTI and APTT (Actin FS and SynthASil), and also on Stago STA Compact Max: ECA and APTT (CK Prest); and site B: Stago STA R Max 2 by ECA and APTT (Cephascreen). RESULTS Mean APTT ratio was 1.96 (Actin FS), 1.84 (SynthASil), 1.59 (CK Prest) and 2.48 (Cephascreen). Mean argatroban concentration by HTI was 0.60 µg/mL and by ECA was 0.65 µg/mL (site A) and 0.70 µg/mL (site B). There was a poor correlation to HTI in APTT ratios (range r2 = .0235-0.4181) with stronger correlations between ECA methods to HTI (r2 = .8998 site A, r2 = .8734 site B). CONCLUSION This study confirms previous publications on the unsuitability of APTT and expands this by being multisited and included APTT reagents that use mechanical clot detection. Both anti-IIa methods are more suitable.
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Affiliation(s)
- Susan Guy
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Barbara Hopkins
- Special Haematology, Leicester Royal Infirmary, Leicester, UK
| | - Zunaid Chunara
- Special Haematology, Leicester Royal Infirmary, Leicester, UK
| | | | - Joost J van Veen
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
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11
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Siguret V, Boissier E, Maistre ED, Gouin-Thibault I, James C, Lasne D, Mouton C, Godon A, Nguyen P, Lecompte T, Ajzenberg N, Bauters A, Béjot Y, Crassard I, Dahmani B, Desconclois C, Flaujac C, Frère C, Godier A, Gruel Y, Hézard N, Jourdi G, Kuadjovi C, Laurichesse M, Mémier V, Mourey G, Reiner P, Tardy B, Toussaint-Hacquard M. GFHT Proposals On The Practical Use Of Argatroban - With Specifics Regarding Vaccine-Induced Immune Thrombotic Thrombocytopaenia (VITT). Anaesth Crit Care Pain Med 2021; 40:100963. [PMID: 34673303 DOI: 10.1016/j.accpm.2021.100963] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
Argatroban is a direct anti-IIa (thrombin) anticoagulant, administered as a continuous intravenous infusion; it has been approved in many countries for the anticoagulant management of heparin-induced thrombocytopaenia (HIT). Argatroban was recently proposed as the non-heparin anticoagulant of choice for the management of patients diagnosed with Vaccine-induced Immune Thrombotic Thrombocytopaenia (VITT). Immunoglobulins are also promptly intravenously administered in order to rapidly improve platelet count; concomitant therapy with steroids is also often considered. An ad hoc committee of the French Working Group on Haemostasis and Thrombosis members has worked on updated and detailed proposals regarding the management of anticoagulation with argatroban, based on previously released guidance for HIT, and adapted for VITT. In case of VITT, the initial dose to be preferred is 1.0 µg x kg-1 x min-1, with further dose-adjustments based on iterative and frequent clinical and laboratory assessments. It is strongly advised to involve a health practitioner experienced in the management of difficult cases in haemostasis. The first laboratory assessment should be performed 4 hours after the initiation of argatroban infusion, with further controls at 2-4-hour intervals until steady state, and at least once daily thereafter. Importantly, full anticoagulation should be rapidly achieved in case of widespread thrombosis. Cerebral vein thrombosis (which is typical of VITT) should not call for an overly cautious anticoagulation scheme. Argatroban administration requires baseline laboratory assessment and should rely on an anti-IIa assay to derive argatroban plasma levels using a dedicated calibration, with a target range between 0.5 and 1.5 µg/mL. Target argatroban plasma levels can be refined based on meticulous appraisal of risk factors for bleeding and thrombosis, on frequent reassessments of clinical status with appropriate vascular imaging, and on the changes in daily platelet counts. Regarding the use of aPTT, baseline value and possible causes for alterations of the clotting time must be taken into account. Specifically, in case of VITT, an aPTT ratio (patient's / mean normal clotting time) between 1.5 and 2.5 is suggested, to be refined according to the sensitivity of the reagent to the effect of a direct thrombin inhibitor. The sole use of aPTT is discouraged: one has to resort to a periodical check with an anti-IIa assay at least, with the help of a specialised laboratory if necessary. Dose modifications should proceed in a stepwise manner with 0.1 to 0.2 µg x kg-1 x min-1 up- or downward changes, taking into account the initial dose, laboratory results, and the whole individual setting. Nomograms are available to adjust the infusion rate. Haemoglobin level, platelet count, fibrinogen plasma level and liver tests should be periodically checked, depending on the clinical status, the more so when unstable.
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Affiliation(s)
- Virginie Siguret
- Hématologie biologique - Hôpital Lariboisière (AP-HP), UMR_S1140, Université de Paris, Paris, France.
| | - Elodie Boissier
- Laboratoire d'hématologie, Hôpital Laënnec, CHU de Nantes, France
| | | | | | - Chloé James
- Laboratoire d'hématologie, CHU de Bordeaux, Pessac, France
| | - Dominique Lasne
- Hématologie biologique - Hôpital Necker-Enfants malades (AP-HP), Paris, UMR_S1176 Université Paris Saclay, Le Kremlin Bicêtre, France
| | | | | | | | - Thomas Lecompte
- Départements de médecine, Hôpitaux Universitaires de Genève, Unité d'hémostase, & Faculté de Médecine - GpG, Université de Genève, Genève, Suisse
| | | | - Anne Bauters
- Service d'hématologie et transfusion, Université de Lille, CHU de Lille, Lille, France
| | | | - Isabelle Crassard
- Neurologie, Hôpital Lariboisière (APHP), FHU NeuroVasculaire, Université de Paris, Paris, France
| | - Bouhadjar Dahmani
- Hémostase et Thrombose, Centre Hospitalier Princesse Grace de Monaco, Monaco
| | | | - Claire Flaujac
- Laboratoire de biologie médicale, secteur hémostase, CH de Versailles, Le Chesnay, France
| | - Corinne Frère
- Hématologie Biologique, Hôpital Pitié Salpêtrière (AP-HP); Sorbonne Université, UMRS 1166, Institut hospitalo-universitaire ICAN, Paris, France
| | - Anne Godier
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou (AP-HP), Paris, France
| | - Yves Gruel
- Hématologie biologique, CHU Tours, Tours, France
| | | | - Georges Jourdi
- Centre de recherche, Institut de Cardiologie de Montréal, Faculté de Pharmacie, Université de Montréal, Canada
| | - Charlène Kuadjovi
- Laboratoire du GCS Nord-Ouest Val d'Oise, CH Pontoise, Pontoise, France
| | | | - Vincent Mémier
- Laboratoire d'Hématologie, CHU Toulouse, Toulouse, France
| | - Guillaume Mourey
- Laboratoire d'Hématologie et d'Immunologie, Établissement Français du Sang Bourgogne -Franche-Comté, Besançon, France
| | - Peggy Reiner
- Service d'hématologie et transfusion, Université de Lille, CHU de Lille, Lille, France
| | - Brigitte Tardy
- INSERM U1059, Université J Monnet, Saint Etienne, France
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Camoin-Jau L, Mariotti A, Suchon P, Morange PE. [Heparin-induced thrombocytopenia: Update]. Rev Med Interne 2021; 43:18-25. [PMID: 34535328 DOI: 10.1016/j.revmed.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/27/2021] [Accepted: 08/29/2021] [Indexed: 11/26/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin therapy. It is due to the synthesis of antibodies most often directed against platelet factor 4 (FP4) modified by heparin (H). HIT is manifested by a platelet count fall, associated with a high risk of venous or arterial thrombosis. The diagnosis of HIT is based on the assessment of clinical probability (4Ts score or change in platelet count after cardiac surgery) and the demonstration of heparin-modified anti-FP4 antibodies (FP4/H). If the immunological tests are positive, functional tests should be performed. In case of suspicion of HIT, it is necessary to urgently stop heparin therapy, to perform a doppler ultrasound of the lower limbs, and to prescribe an alternative anticoagulation agent at a curative dose. Currently, danaparoid sodium and argatroban are authorized. The diagnosis and management of HIT remain complex and requires multidisciplinary collaboration.
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Affiliation(s)
- L Camoin-Jau
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; Aix-Marseille univsersité, IRD, AP-HM, MEPHI, IHU Méditerranée infection, Marseille, France.
| | - A Mariotti
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France
| | - P Suchon
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; C2VN, Aix-Marseille université, Inserm, INRAE, Marseille, France
| | - P-E Morange
- Laboratoire d'hématologie, hôpital de la Timone, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; C2VN, Aix-Marseille université, Inserm, INRAE, Marseille, France
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13
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Páramo JA, Lozano ML, González-Porras JR, Mateo J. Current status of diagnosis and treatment of heparin-induced thrombocytopenia (HIT). Med Clin (Barc) 2021; 158:82-89. [PMID: 34311973 DOI: 10.1016/j.medcli.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 12/01/2022]
Affiliation(s)
- José A Páramo
- Servicio de Hematología Clínica, Universidad de Navarra, Pamplona, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, España; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, España.
| | - Mª Luisa Lozano
- Departmento de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Murcia, España; Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia, España
| | | | - José Mateo
- Unidad de Hemostasia y Trombosis, Servicio de Hematología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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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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Colarossi G, Maffulli N, Trivellas A, Schnöring H, Hatam N, Tingart M, Migliorini F. Superior outcomes with Argatroban for heparin-induced thrombocytopenia: a Bayesian network meta-analysis. Int J Clin Pharm 2021; 43:825-838. [PMID: 33774764 PMCID: PMC8352815 DOI: 10.1007/s11096-021-01260-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 03/15/2021] [Indexed: 12/20/2022]
Abstract
Background Argatroban, lepirudin, desirudin, bivalirudin, and danaparoid are commonly used to manage heparin-induced thrombocytopenia related complications. However, the most suitable drug for this condition still remains controversial. Aim of the review This Bayesian network meta-analysis study compared the most common anticoagulant drugs used in the management of heparin-induced thrombocytopenia. Method All clinical trials comparing two or more anticoagulant therapies for suspected or confirmed heparin-induced thrombocytopenia were considered for inclusion. Studies concerning the use of heparins or oral anticoagulants were not considered. Data concerning hospitalisation length, thromboembolic, major, and minor haemorrhagic events, and mortality rate were collected. The network analyses were made through the STATA routine for Bayesian hierarchical random-effects model analysis with standardised mean difference (SMD) and log odd ratio (LOR) effect measures. Results Data from a total of 4338 patients were analysed. The overall mean age was 62.31 ± 6.6 years old. Hospitalization length was considerably shorter in favour of the argatroban group (SMD: − 1.70). Argatroban evidenced the lowest rate of major (LOR: − 1.51) and minor (LOR: − 0.57) haemorrhagic events. Argatroban demonstrated the lowest rate of thromboembolic events (LOR: 0.62), and mortality rate (LOR: − 1.16). Conclusion Argatroban performed better overall for selected patients with HIT. Argatroban demonstrated the shortest hospitalization, and lowest rate of haemorrhages, thromboembolisms, and mortality compared to bivalirudin, lepirudin, desirudin, and danaparoid.
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Affiliation(s)
- Giorgia Colarossi
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
| | - Heike Schnöring
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Nima Hatam
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Markus Tingart
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
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16
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Colarossi G, Schnöring H, Trivellas A, Betsch M, Hatam N, Eschweiler J, Tingart M, Migliorini F. Prognostic factors for patients with heparin-induced thrombocytopenia: a systematic review. Int J Clin Pharm 2020; 43:449-460. [PMID: 33044680 DOI: 10.1007/s11096-020-01166-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/23/2020] [Indexed: 10/23/2022]
Abstract
Background Little is known with regards to the prognostic factors for patients with suspected or diagnosed Heparin-Induced Thromobocytopenia (HIT). The role of patient and therapy characteristics may play a role in predicting the outcome. Aim of the review To investigate the role of patient and therapy characteristics as potential prognostic factors for HIT-related complications (haemorrhagic and thromboembolic events), and mortality. Method The present systematic review was conducted according to the PRISMA statement. In September 2020, the main online databases were accessed: Pubmed, EMBASE, Scopus, Google Scholar. All the clinical trials concerning the management of patients with suspected or confirmed HIT were eligible. Studies evaluating the use of oral anticoagulants (e.g. vitamin K antagonists, Apixaban) were not considered, along with those comparing the use of heparin. For pairwise correlation, the Pearson Product-Moment Correlation Coefficient (r) was used. The final effect was evaluated according to the Cauchy-Schwarz inequality.Results Data from 33 clinical studies (4338 patients) were retrieved. The overall mean age was 62.3 ± 6.6 years old. Patients with HIT-related thromboembolism at the moment of diagnosis were associated with greater rate of haemorrhages (P > 0.0001), thromboembolism (P > 0.0001) and mortality (P = 0.001). Patients with more comorbidities at diagnosis were associated with a greater risk of haemorrhages (P = 0.07), thromboembolism (P = 0.002) and mortality (P = 0.002). Patients with longer duration of the therapy were associated with lower rate of mortality (P = 0.04). ConclusionsPatient comorbidities, presence of HIT-related thromboembolism on admission and shorter anticoagulant therapy were found to be negative prognostic factors. Thrombocythemia on admission, patients age and gender did not influence the overall outcome.
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Affiliation(s)
- Giorgia Colarossi
- Department of Cardiac and Thoracic Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Heike Schnöring
- Department of Cardiac and Thoracic Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Marcel Betsch
- Women´s College Hospital, University of Toronto Orthopaedic Sports Medicine Program (UTOSM), Toronto, ON, Canada
| | - Nima Hatam
- Department of Cardiac and Thoracic Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Jörg Eschweiler
- Department of Orthopaedics Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Markus Tingart
- Department of Orthopaedics Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Filippo Migliorini
- Department of Orthopaedics Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany.
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18
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Bachler M, Hell T, Bösch J, Treml B, Schenk B, Treichl B, Friesenecker B, Lorenz I, Stengg D, Hruby S, Wallner B, Oswald E, Ströhle M, Niederwanger C, Irsara C, Fries D. A Prospective Pilot Trial to Assess the Efficacy of Argatroban (Argatra ®) in Critically Ill Patients with Heparin Resistance. J Clin Med 2020; 9:jcm9040963. [PMID: 32244368 PMCID: PMC7230377 DOI: 10.3390/jcm9040963] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/21/2020] [Accepted: 03/27/2020] [Indexed: 12/02/2022] Open
Abstract
The current study aims to evaluate whether prophylactic anticoagulation using argatroban or an increased dose of unfractionated heparin (UFH) is effective in achieving the targeted activated partial thromboplastin time (aPTT) of more than 45 s in critically ill heparin-resistant (HR) patients. Patients were randomized either to continue receiving an increased dose of UFH, or to be treated with argatroban. The endpoints were defined as achieving an aPTT target of more than 45 s at 7 h and 24 h. This clinical trial was registered on clinicaltrials.gov (NCT01734252) and on EudraCT (2012-000487-23). A total of 42 patients, 20 patients in the heparin and 22 in the argatroban group, were included. Of the patients with continued heparin treatment 55% achieved the target aPTT at 7 h, while only 40% of this group maintained the target aPTT after 24 h. Of the argatroban group 59% reached the target aPTT at 7 h, while at 24 h 86% of these patients maintained the targeted aPTT. Treatment success at 7 h did not differ between the groups (p = 0.1000), whereas at 24 h argatroban showed significantly greater efficacy (p = 0.0021) than did heparin. Argatroban also worked better in maintaining adequate anticoagulation in the further course of the study. There was no significant difference in the occurrence of bleeding or thromboembolic complications between the treatment groups. In the case of heparin-resistant critically ill patients, argatroban showed greater efficacy than did an increased dose of heparin in achieving adequate anticoagulation at 24 h and in maintaining the targeted aPTT goal throughout the treatment phase.
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Affiliation(s)
- Mirjam Bachler
- Institute for Sports Medicine, Alpine Medicine and Health Tourism, UMIT - University for Health Sciences, Medical Informatics and Technology, 6060 Hall in Tirol, Austria;
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, 6020 Innsbruck, Austria;
| | - Johannes Bösch
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Benedikt Treml
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
- Correspondence: ; Tel.: +43-050-504-822-31
| | - Bettina Schenk
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Benjamin Treichl
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (E.O.)
| | - Barbara Friesenecker
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Ingo Lorenz
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Daniel Stengg
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Stefan Hruby
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Bernd Wallner
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (E.O.)
| | - Elgar Oswald
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (E.O.)
| | - Mathias Ströhle
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Christian Niederwanger
- Department of Pediatrics, Pediatrics I, Intensive Care Unit, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Christian Irsara
- Central Institute for Medical and Chemical Laboratory Diagnostics, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Dietmar Fries
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
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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: 62] [Impact Index Per Article: 15.5] [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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Abstract
The evaluation and management of thrombocytopenia is a daily challenge for clinicians in the intensive care unit (ICU). Thrombocytopenia is incredibly common, present in upwards of 60% of ICU patients. Additionally, thrombocytopenia in the critically ill is rarely caused by a single etiology. Several causes of thrombocytopenia in the ICU including heparin-induced thrombocytopenia (HIT) and thrombotic thrombocytopenic purpura demand urgent recognition and intervention. This chapter provides a general overview of thrombocytopenia in the ICU and highlights important diagnostic and management considerations for some of the most common etiologies.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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21
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Elalamy I, Arnaud P, Baconnet O, André MH, Tellier Z. [Argatroban in heparin-induced thrombocytopenia: A survey of prescribing practices and use in France]. Therapie 2019; 75:543-552. [PMID: 32540143 DOI: 10.1016/j.therap.2019.12.008] [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] [Received: 06/05/2019] [Revised: 09/20/2019] [Accepted: 12/12/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A survey of prescribing practices was carried out in France to ensure that argatroban was used appropriately during the first 18months after it obtained marketing authorization for anticoagulation in adults with heparin-induced thrombocytopenia (HIT). METHODS This observational study was proposed to public and private hospitals with at least 2 orders of argatroban. All patients who received at least one argatroban injection during the study period had to be included. Their demographic characteristics, the pathology causing heparin treatment, the indication of treatment with argatroban, as well as available real-life clinical and biological monitoring data were retrospectively collected. RESULTS In the 23 participating centers, the drug was prescribed mainly by the following hospital units: surgery and intensive care (79.3%) (of which 18.3% cardiovascular), nephrology/hemodialysis (14.8%) and internal medicine (5.9%). Among the 169 patients included, with median age of 68 years, 118 (69.8%) had renal impairment (creatinine clearance <90mL/min). The HIT probability scoring and diagnostic tests used differed widely between the centers. The reasons for prescribing the drug were mainly suspected HIT (51.5%), declared confirmed HIT (21.3%) or a history of HIT (14.8%). Seventy-three (73) patients (43.2%) had thrombotic symptoms or a systemic reaction initially. The median initial dose prescribed was 0.5μg/kg/min (ranging from 0.05 to 4.42) and doses >2μg/kg/min were used during hemodialysis. More than half of the patients (58.6%) had no clinical complications. Most of the serious adverse reactions were hemorrhagic (11/12). CONCLUSION This study illustrates the complexity of treatment for HIT and the need to be familiar with and follow guidelines on the management of HIT, especially for susceptible patients treated in intensive care units.
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Affiliation(s)
- Ismaïl Elalamy
- Hématologie biologique, hôpital Tenon, AP-HP, 75020 Paris, France
| | - Philippe Arnaud
- Pharmacie à usage intérieur, hôpital Bichat-Claude-Bernard, AP-HP, 75018 Paris, France
| | - Ophélie Baconnet
- Direction des affaires médicales, LFB biomédicaments, 3, avenue des Tropiques, 91958 Les Ulis, France
| | - Marie-Hélène André
- Direction des affaires médicales, LFB biomédicaments, 3, avenue des Tropiques, 91958 Les Ulis, France
| | - Zéra Tellier
- Direction des affaires médicales, LFB biomédicaments, 3, avenue des Tropiques, 91958 Les Ulis, France.
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Beyer JT, Lind SE, Fisher S, Trujillo TC, Wempe MF, Kiser TH. Evaluation of intravenous direct thrombin inhibitor monitoring tests: Correlation with plasma concentrations and clinical outcomes in hospitalized patients. J Thromb Thrombolysis 2019; 49:259-267. [PMID: 31559512 DOI: 10.1007/s11239-019-01961-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The parenterally administered direct thrombin inhibitors (DTIs) argatroban and bivalirudin are effective anticoagulants for acute heparin-induced thrombocytopenia (HIT) treatment. The activated partial thromboplastin time (aPTT) has classically been used as the monitoring test to assess degree of anticoagulation, however concerns exist with using aPTT to monitor DTI therapy. In this observational study plasma samples from DTI treated patients were analyzed by aPTT, dilute thrombin time (dTT) and ecarin chromogenic assay (ECA) to delineate results into concordant and discordant groups. Discordant samples were further analyzed via liquid chromatography with tandem mass spectrometry (LC MS/MS). In total 101 patients with 198 samples were evaluated. Discordance between tests were frequent (59% of DTI treated patients). Bivalirudin aPTT vs dTT discordance was observed in 45% (57/126) of samples. Amongst bivalirudin samples with test discordance dTT results were more likely to be concordant with LC MS/MS than the aPTT (77% vs 9%, p < 0.0001). Argatroban aPTT vs dTT discordance was observed in 43% (31/72) and aPTT vs ECA discordance was observed in 40% (29/72) of samples. Amongst argatroban samples with test discordance both the dTT and ECA tests were more likely to have concordant results with LC MS/MS than the aPTT (88% vs 9%, p < 0.0001 for both dTT and ECA tests). There were no differences between discordant and concordant patient groups in a composite outcome of bleeding/thrombosis rate (23% vs 27%, p = 0.689). Further investigation is warranted to elucidate the effect of suitable monitoring assays on patient outcomes in the setting of DTI therapy.
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Affiliation(s)
- Jacob T Beyer
- Department of Pharmacy, Denver Health Medical Center, Denver, CO, USA
| | - Stuart E Lind
- Departments of Medicine and Pathology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sheila Fisher
- Clinical Laboratory, University of Colorado Hospital, Aurora, CO, USA
| | - Toby C Trujillo
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, 12850 E Montview Blvd, C238, Aurora, CO, 80045, USA
| | - Michael F Wempe
- Medicinal Chemistry Core Facility, Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, 12850 E Montview Blvd, C238, Aurora, CO, 80045, USA.
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European guidelines on perioperative venous thromboembolism prophylaxis: Intensive care. Eur J Anaesthesiol 2019; 35:142-146. [PMID: 29112545 DOI: 10.1097/eja.0000000000000707] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
: Venous thromboembolism is a common and potentially life-threatening complication that occurs in 4 to 15% of patients admitted to ICUs despite the routine use of pharmacological prophylaxis. We therefore recommend an institution-wide protocol for the prevention of venous thromboembolism (Grade 1B). The routine use of ultrasonographic screening for deep vein thrombosis is not recommended when thromboprophylactic measures are in place (Grade 1B), as the detection of asymptomatic deep vein thrombosis may prompt therapeutic anticoagulation that may increase bleeding risk but has no proven reduction of clinically significant thrombotic events. In critically ill patients, we recommend pharmacological prophylaxis with low molecular weight heparin over low-dose heparin (Grade 1B). For critically ill patients with severe renal insufficiency, we suggest the use of low-dose heparin (Grade 2C), dalteparin (Grade 2B) or reduced doses of enoxaparin (Grade 2C). Monitoring of anti-Xa activity may be considered when low molecular weight heparin is used in these patients (Grade 2C). No study has prospectively evaluated the efficacy and safety of deep vein thrombosis prophylaxis in critically ill patients with severe liver dysfunction. Thus, the use of pharmacological prophylaxis in these patients should be carefully balanced against the risk of bleeding. For critically ill patients, we recommend against the routine use of inferior vena cava filters for the primary prevention of venous thromboembolism (Grade 1C). When the diagnosis of heparin-induced thrombocytopaenia is suspected or confirmed, all forms of heparin must be discontinued (Grade 1B). In these patients, immediate anticoagulation with a nonheparin anticoagulant rather than discontinuation of heparin alone is recommended (Grade 1C).
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Thrombin contributes to the injury development and neurological deficit after acute subdural hemorrhage in rats only in collaboration with additional blood-derived factors. BMC Neurosci 2018; 19:81. [PMID: 30591020 PMCID: PMC6307215 DOI: 10.1186/s12868-018-0481-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/15/2018] [Indexed: 12/13/2022] Open
Abstract
Background Acute subdural hemorrhage (ASDH) is a severe consequence of traumatic brain injury. The occurrence of subdural blood increases the lethality of these patients independent of the amount of blood or elevated intracranial pressure. Thrombin is one of the potential harmful blood components. Possible harmful effects of thrombin are mediated via the Protease-activated-receptor-1 (PAR1) and thus, translating the acute Thrombin release after ASDH into cell loss. The objectives of the present study were twofold, namely to examine (1) the impact of direct thrombin inhibition in the acute phase after hemorrhage on the long-term histological and functional deficits and (2) the early inhibition of PAR1 activation by thrombin with the selective antagonist SCH79797 on lesion volume at 14 days after ASDH. The effects of thrombin on the lesion size were investigated in two separate experiments via (1) direct thrombin inhibition in the subdural infused blood (Argatroban 600 µg) as well as by (2) intraventricular injection of the PAR-1 antagonist SCH79797 (1 µg or 5 µg). Lesion volume and behavior deficits using a neurological deficit score and a motor function test (beam balance test) were analyzed as outcome parameters at 14 days after injury. Results 59 Male Sprague–Dawley rats received a subdural infusion of 300 µl autologous blood or sham operation. Lesion volume at 14 days after ASDH tended to be smaller in the Argatroban-treated group when compared to the vehicle group (8.1 ± 1.1 vs. 10.1 ± 2.3 mm2, n.s.). Motor deficits in the beam balance test were not significantly less severe in the Argatroban-treated group. Animals treated with SCH79797 also showed a trend towards dose-dependent decreased lesion volume in comparison to the vehicle-treated group (1 μg: 4.3 ± 0.7 mm3; 5 μg: 3.8 ± 1.1 mm3; vehicle: 6.5 ± 2.0 mm3, n.s). Conclusions Thrombin inhibition in the subdural blood and local cerebral blockade of PAR-1 cause a tendency towards reduced lesion volume or functional recovery. All results show a trend in favor of the acute treatment on the outcome parameters. Our results suggests that thrombin could be an important blood-derived factor during acute subdural hemorrhage that translates its deleterious effects in concert with other blood-induced factors.
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Al-Eidan FAS, Alrawkan S, Alshammary H, Crowther MA. Comparison of argatroban and fondaparinux for the management of patients with isolated heparin-induced thrombocytopenia. Ann Hematol 2018; 97:2055-2059. [PMID: 30003318 DOI: 10.1007/s00277-018-3422-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 06/27/2018] [Indexed: 11/30/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious complication of the administration of heparin and its derivatives. Non-heparin anticoagulants such as argatroban and fondaparinux are widely used in the management of HIT to compare the effectiveness of argatroban and fondaparinux in the resolution of thrombocytopenia and to compare clinical outcomes in patients with isolated HIT. A retrospective cohort analysis was performed at King Abdulaziz Medical City (KAMC) on patients diagnosed with isolated HIT between 31 Jan, 2014 and 30 June, 2017. Demographics data, non-heparin anticoagulants, related laboratory results, and clinical outcomes were retrieved and analysed. The cohort comprised a total of 95 adult patients who received either argatroban (56 patients) or fondaparinux (39 patients) for isolated HIT. The median age and sex distribution were similar in both argatroban and fondaparinux groups. The mean (+ SD) time (in days) for the resolution of thrombocytopenia was 3.5 (± 1.8) for patients who received argatroban and 3.7 (± 1.7) for patients administered fondaparinux (p = 0.843). Thromboembolic events occurred in five patients (8.9%) administered argatroban and in three patients (7.7%) administered fondaparinux (p = 0.382). There was no significant difference in the rates of bleeding or death (p = 0.829); however, the small number of cases limits our ability to draw conclusions about these outcomes. In this retrospective study, fondaparinux and argatroban were similarly effective in resolving thrombocytopenia, preventing further thromboembolic events, and maintaining safety in patients with confirmed HIT. To confirm this observation, larger prospective studies are needed.
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Affiliation(s)
- Fahad A S Al-Eidan
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia. .,King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Saud Alrawkan
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Gameiro J, Jorge S, Lopes JA. Haemodialysis-related-heparin-induced thrombocytopenia: Case series and literature review. Nefrologia 2018; 38:551-557. [PMID: 29871769 DOI: 10.1016/j.nefro.2018.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 02/12/2018] [Accepted: 02/27/2018] [Indexed: 01/18/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious and life-threatening complication that occurs in five per cent of patients exposed to heparin. It should be considered in patients with a platelet count <100×109cells/l or a >50% decrease from baseline count in association with heparin therapy. Thromboembolic complications develop in 50% of patients. Bleeding is rare as the platelet count nadir typically does not drop below 20×109cells/l. Up to 12% of dialysis patients develop HIT, named haemodialysis-related-heparin-induced thrombocytopenia (HD-HIT), as they are a risk group with continuous exposure to heparin. The definition of HD-HIT is less strict, in the range of a platelet count decrease of 30% and below 150×109cells/l due to the intermittent use of heparin. Heparin cessation and alternative anticoagulation are the key interventions in patients with HIT. In dialysis patients, citrate anticoagulation, heparin-free dialysis or peritoneal dialysis are options that must be considered. The authors describe the presentation, diagnosis, treatment and outcomes of five cases of HD-HIT, and emphasize the importance of an accurate diagnosis and early intervention in order to reduce the mortality risk, which can be as high as 20 per cent.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal.
| | - Sofia Jorge
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - José António Lopes
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
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Fu X, Ning JP. Synthesis and biocompatibility of an argatroban-modified polysulfone membrane that directly inhibits thrombosis. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2018; 29:66. [PMID: 29744595 DOI: 10.1007/s10856-018-6054-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 04/04/2018] [Indexed: 06/08/2023]
Abstract
Anticoagulation therapy plays a vital role in the prevention of blood clot formation during hemodialysis and hemofiltration, especially for critical care patients. Here, we synthesized a novel argatroban (Arg)-modified polysulfone (PSf) membrane for anticoagulation. Arg was grafted onto the PSF membrane via chemical modification to increase membrane hydrophilicity. Protein adsorption, coagulation, as well as activation of platelets and complement systems were greatly reduced on the Arg-modified PSf membrane. Thus, the recalcification time and the activated partial thrombin time (APTT) were increased after the modification. In comparison with the pristine PSf membrane, the Arg-modified PSf membrane showed better hemocompatibility and anticoagulation properties, indicating its potential for applications in hemodialysis and hemofiltration. Modification of the PSf membrane has been investigated in attempts to further enhance the anticoagulation properties of the hemodialysis membranes, including a heparin-modified PSf membrane. However, heparin can inhibit plasma-free thrombin, and cause the occurrence of heparin-induced thrombocytopenia (HIT), which increases the risk of bleeding during dialysis in critical care patients. To address this problem, we modified PSf membrane with as a novel direct thrombin inhibitors, argatroban (Arg). It can reversibly bind to thrombin, inhibiting not only the plasma-free thrombin in the blood, but also clot-bound thrombin.
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Affiliation(s)
- Xiao Fu
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, 410008, China
| | - Jian-Ping Ning
- Department of Nephropathy, Xiangya Hospital, Central South University, Changsha, 410008, China.
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Guy S, Kitchen S, Van Veen JJ. Argatroban is stable in citrated whole blood for 24 hours. Int J Lab Hematol 2018; 40:484-487. [PMID: 29707901 DOI: 10.1111/ijlh.12844] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/22/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Argatroban is a direct thrombin inhibitor used as an anticoagulant for patients who have Heparin induced thrombocytopenia. Quantification can be performed using a dilute thrombin time or anti-iia assay. Our preferred method is Hemoclot Thrombin Inhibitor Assay (HTI).To the best of our knowledge, no one has published on the stability of plasma argatroban in whole citrated blood at room temperature. METHODS Forty matched samples obtained from 4 patients receiving argatroban. 1 mL of the whole blood was removed from the sample into a labelled plastic tube and left on the laboratory bench at room temperature for 24 hours prior to centrifugation. The remaining sample was spun at 2000 g for 10 minutes and the plasma aliquoted off and labelled 0 hour and stored at -80°C prior to testing. At 24 hours the plastic tube containing whole blood was centrifuged at 2000 g for 10 minutes and the plasma aliquoted off and labelled 24 hours and stored at -80°C prior to testing. HTI assay was used for plasma argatroban determination. RESULTS The lowest argatroban level obtained was 0.16 μg/mL at 0 hour; 0.18 μg/mL at 24 hours from the same pair, the highest argatroban level obtained was 1.72 μg/mL at 0 hour;1.76 μg/mL for the same pair at 24 hours. The mean result for 0 hour was 0.57 μg/mL and 0.60 μg/mL at 24 hours. CONCLUSION This study proposes that patients receiving treatment in hospitals who cannot provide a dedicated argatroban plasma concentration method could have their samples sent on whole blood within 24 hours of venepuncture to a laboratory who could provide the test.
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Affiliation(s)
- S Guy
- Sheffield Thrombosis and Haemostasis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - S Kitchen
- Sheffield Thrombosis and Haemostasis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - J J Van Veen
- Sheffield Thrombosis and Haemostasis Centre, Royal Hallamshire Hospital, Sheffield, UK
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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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Selleng S, Selleng K. Heparin-induced thrombocytopenia in cardiac surgery and critically ill patients. Thromb Haemost 2017; 116:843-851. [DOI: 10.1160/th16-03-0230] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/16/2016] [Indexed: 11/05/2022]
Abstract
SummaryThrombocytopenia as well as anti-platelet factor 4/heparin (PF4/H) antibodies are common in cardiac surgery patients and those treated in the intensive care unit. In contrast, heparin-induced thrombocytopenia (HIT) is uncommon in these populations (∼1 % and ∼0.5 %, respectively). A stepwise approach where testing for anti-PF4/H antibodies is performed only in patients with typical clinical symptoms of HIT improves diagnostic specificity of the laboratory assays without losing sensitivity, thereby helping to avoid overdiagnosis and resulting HIT overtreatment. Short-term re-exposure to heparin, especially given intraoperatively for cardiovascular surgery, is a reasonable therapeutic option in patients with a history of HIT who subsequently test negative for HIT antibodies. Organ failure(s), enhanced bleeding risks, and other characteristics require special considerations regarding non-heparin anticoagulation: Argatroban is the alternative anticoagulant with pharmacokinetics independent of renal function, but it has a prolonged half-life in case of impaired liver function. For bivalirudin, protocols during cardiopulmonary bypass surgery are established, and it is suitable for patients with liver insufficiency. A major issue of direct thrombin inhibitors are false high activated partial thromboplastin time values in patients with comorbidities affecting prothrombin, which can result in systematic underdosing of the drugs. This is not the case for danaparoid and fondaparinux, which can be monitored by anti-factor Xa assays, but have long half-lives and no suitable antidote. This review includes also information on management of on- and off-pump cardiac surgery, ventricular assist devices, percutaneous interventions, continuous renal replacement therapy, and extracorporeal membrane oxygenation in patients with HIT.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent findings on heparin-induced thrombocytopenia (HIT), a prothrombotic disorder caused by platelet-activating IgG targeting platelet factor 4 (PF4)/polyanion complexes. RECENT FINDINGS HIT can explain unusual clinical events, including adrenal hemorrhages, arterial/intracardiac thrombosis, skin necrosis, anaphylactoid reactions, and disseminated intravascular coagulation. Sometimes, HIT begins/worsens after stopping heparin ('delayed-onset' HIT). Various HIT-mimicking disorders are recognized (e.g., acute disseminated intravascular coagulation/'shock liver' with limb ischemia). HIT has features of both B-cell and T-cell immune responses; uptake of PF4/heparin complexes into macrophages ('macropinocytosis') facilitates the anti-PF4/heparin immune response. Antibody-induced activation of monocytes and platelets via their FcγIIA receptors triggers an intense procoagulant response. Sometimes, HIT antibodies recognize PF4 bound to (platelet-associated) chondroitin sulfate, explaining how HIT might occur without concurrent or recent heparin (delayed-onset HIT, 'spontaneous HIT syndrome'). The molecular structure of HIT antigen(s) has been characterized, providing a rationale for future drug design to avoid HIT and improve its treatment. The poor correlation between partial thromboplastin time and plasma argatroban levels (risking subtherapeutic anticoagulation) and need for intravenous administration of argatroban have led to increasing 'off-label' treatment with fondaparinux or one of the direct oral anticoagulants. SUMMARY Understanding the molecular mechanisms and unusual clinical features of HIT will improve its management.
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Zhang L, Yang J, Zheng X, Fan Q, Zhang Z. Influences of argatroban on five fibrinogen assays. Int J Lab Hematol 2017; 39:641-644. [PMID: 28766891 DOI: 10.1111/ijlh.12719] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/16/2017] [Indexed: 12/11/2022]
Affiliation(s)
- L. Zhang
- Department of Pathology and Clinical Laboratory (DPCL); Wuhan Asia Heart Hospital (WAHH); Wuhan China
| | - J. Yang
- Department of Pathology and Clinical Laboratory (DPCL); Wuhan Asia Heart Hospital (WAHH); Wuhan China
| | - X. Zheng
- Department of Pathology and Clinical Laboratory (DPCL); Wuhan Asia Heart Hospital (WAHH); Wuhan China
| | - Q. Fan
- Department of Pathology and Clinical Laboratory (DPCL); Wuhan Asia Heart Hospital (WAHH); Wuhan China
| | - Z. Zhang
- Department of Pathology and Clinical Laboratory (DPCL); Wuhan Asia Heart Hospital (WAHH); Wuhan China
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Comparisons of argatroban to lepirudin and bivalirudin in the treatment of heparin-induced thrombocytopenia: a systematic review and meta-analysis. Int J Hematol 2017; 106:476-483. [DOI: 10.1007/s12185-017-2271-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 05/24/2017] [Accepted: 05/31/2017] [Indexed: 11/25/2022]
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Guy S, Kitchen S, Van Veen JJ. Further evidence of the limitations of Activated Partial Thromboplastin Time to monitor Argatroban. Br J Haematol 2016; 180:594-597. [DOI: 10.1111/bjh.14397] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Susan Guy
- Sheffield Thrombosis and Haemophilia Centre; Royal Hallamshire Hospital; Sheffield UK
| | - Steve Kitchen
- Sheffield Thrombosis and Haemophilia Centre; Royal Hallamshire Hospital; Sheffield UK
| | - Joost J. Van Veen
- Sheffield Thrombosis and Haemophilia Centre; Royal Hallamshire Hospital; Sheffield UK
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Ho PJ, Siordia JA. Dabigatran approaching the realm of heparin-induced thrombocytopenia. Blood Res 2016; 51:77-87. [PMID: 27382551 PMCID: PMC4931941 DOI: 10.5045/br.2016.51.2.77] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 06/14/2016] [Accepted: 06/14/2016] [Indexed: 02/02/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious, immune mediated complication of exposure to unfractionated or low-molecular-weight heparin. Though rare, it is a condition associated with high morbidity and mortality that requires immediate change to alternative anticoagulants for the prevention of life-threatening thrombosis. The direct thrombin inhibitors lepirudin and argatroban are currently licensed for the treatment of HIT. Dabigatran, a novel oral anticoagulant (NOAC) with a similar mechanism of action and effective use in other indications, has recently been proposed as another therapeutic option in cases of HIT. This review serves as an introduction to using dabigatran for this purpose, detailing the clinical aspects of its administration, evidence of its performance compared to other anticoagulants, and the preliminary reports of HIT successfully treated with dabigatran. As the literature on this develops, it will need to include clinical trials that directly evaluate dabigatran against the other NOACs and current treatment options.
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Affiliation(s)
- Patricia J Ho
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Juan A Siordia
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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Honore PM, Jacobs R, Hendrickx I, De Waele E, Van Gorp V, Spapen HD. Fondaparinux: another potential treatment for heparin-induced thrombocytopenia type II? Crit Care 2015; 20:14. [PMID: 26812984 PMCID: PMC4729072 DOI: 10.1186/s13054-016-1196-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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