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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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Comparison of a predefined dose increment nomogram with a percentage adjustment nomogram in patients receiving argatroban therapy. J Am Pharm Assoc (2003) 2020; 60:702-707. [DOI: 10.1016/j.japh.2020.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/21/2020] [Accepted: 01/26/2020] [Indexed: 11/23/2022]
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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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Heparin-Induced Thrombocytopenia. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Zimmer E, Bek M, Wiessner M, Keyl C, Trenk D. Argatroban pharmacokinetics and pharmacodynamics in critically ill cardiac surgical patients with suspected heparin-induced thrombocytopenia. Thromb Haemost 2017; 115:1081-9. [DOI: 10.1160/th15-11-0847] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 12/28/2015] [Indexed: 11/05/2022]
Abstract
SummaryOnly limited data are available on the pharmacokinetic and pharmacodynamic properties of argatroban in critically ill patients under clinical conditions. We determined plasma concentrations of argatroban, and its main metabolite M1, within a time period of 48 hours in 25 critically ill cardiac surgical patients, who were suspected of heparininduced thrombocytopenia and had the clinical need for anticoagulation. Argatroban infusion was started at 0.5 µg/kg/minute, and adjusted in 0.1–0.25 µg/kg/minute increments when the activated partial thromboplastin time (aPTT) was not within the target range. Median argatroban plasma half-life was 2.7 hours (interquartile range 1.8 to 7.3). Linear regression analysis revealed that argatroban half-life was significantly related to the total bilirubin concentration (R2 = 0.66, p< 0.001), as well as to the metabolism of argatroban, which was assessed by the ratio of the areas under the concentration time curves (AUC) of argatroban and M1 (R2 = 0.60, p< 0.001). Continuous veno-venous haemodialysis did not significantly affect argatroban plasma half-life. The predictive property of argatroban plasma levels for aPTT was low (R2 = 0.28, p< 0.001). Multiple linear regression analysis revealed significant contributions of age and serum albumin levels to the effect of argatroban on aPTT, expressed as the AUC ratio argatroban/aPTT (R2 = 0.67, adjusted R2 = 0.65, p< 0.001). In conclusion, argatroban plasma half-life is markedly increased in critically ill cardiac surgical patients, and further prolonged by hepatic dysfunction due to impaired metabolism. Patient age and serum albumin concentration significantly contribute to the variability in the anticoagulant activity of argatroban.
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Abstract
Thrombocytopenia is commonly seen in laboratory findings, especially in critically ill patients. Although the incidence is rare, drug-induced immune thrombocytopenia (DITP) is a serious complication that is often overlooked as a cause of thrombocytopenia. Over the last century, extensive research and data collection have been done in an attempt to better characterize DITP. Heparin-induced thrombocytopenia is the most common DITP and has distinct pathogenesis, diagnosis, and treatment options. However, other offending medications are less well known and have triggered many questions and constant search for answers. This review will discuss both drug-induced immune-mediated and nonimmune-mediated thrombocytopenias, with a focus on immune-mediated processes. Thrombocytopenia caused by chemotherapy will not be discussed in this article.
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Affiliation(s)
- Teresa Kam
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Maurice Alexander
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
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Burcham PK, Abel EE, Gerlach AT, Murphy CV, Belcher M, Blais DM. Development and implementation of a nurse-driven, sliding-scale nomogram for bivalirudin in the management of heparin-induced thrombocytopenia. Am J Health Syst Pharm 2014; 70:980-7. [PMID: 23686604 DOI: 10.2146/ajhp120246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE A simplified dosing nomogram to assist nurses in adjusting the rate of i.v. bivalirudin administration in cases of heparin-induced thrombocytopenia (HIT) is described. SUMMARY To facilitate the availability of bivalirudin [corrected] as an alternative direct thrombin inhibitor (DTI) for patients with HIT at The Ohio State University Wexner Medical Center (OSUWMC), a team of clinical pharmacists developed a nomogram designed to simplify infusion dosage adjustments by nurses. In contrast to bivalirudin nomograms requiring patient-specific, percentage-based dose adjustments, the nomogram developed at OSUWMC specifies fixed adjustments (0.005 or 0.01 mg/kg/hr) according to the current activated partial thromboplastin time (aPTT) value relative to aPTT goals. During pilot testing over three years, the nomogram was used to guide dosage adjustments in 65 adult patients receiving continuous infusions of bivalirudin for suspected or confirmed HIT in intensive care units. Overall, the use of the nomogram resulted in adequate anticoagulation, with 53.7% of all measured aPTT values in the target range; 30.5% of aPTT values were below target, and 15.8% of values were above target. The median time to steady state was 11.0 hours (range, 5.0-31.8 hours), and bleeding rates were consistent with those reported in the literature. Nurse adherence to the nomogram was 100%, and no dosing errors occurred during a total of 487 dosage changes. Based on the pilot study results, the nomogram was refined to improve initial dosing for patients with creatinine clearance values of >30 mL/min; other refinements were made to enhance the safety of bivalirudin therapy for HIT in patients with severe renal impairment. CONCLUSION A nurse-driven, sliding-scale nomogram for bivalirudin therapy in patients with HIT provided a simple dosing protocol and resulted in a high rate of adherence by nurses.
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Affiliation(s)
- Pamela K Burcham
- The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
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Arpino PA, Goeller AJ, Fatalo A, Van Cott EM. Evaluation of 2 Nomogram-Based Strategies for Dosing Argatroban in Patients With Known or Suspected Heparin-Induced Thrombocytopenia. Clin Appl Thromb Hemost 2013; 21:260-5. [DOI: 10.1177/1076029613501542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
No study has compared 2 different dosing strategies for argatroban titration nor has any published nomogram demonstrated improvement in outcomes. This study was conducted to evaluate the effectiveness of 2 argatroban nomograms on reaching therapeutic anticoagulation. Patients treated with argatroban were separated into 2 sliding scale groups, percentage adjustments (PAs) and predefined dose increments (PDIs). The primary outcome was the time to reach a therapeutic activated partial thromboplastin time (aPTT). The average initial dose and dose to achieve a therapeutic aPTT were similar between the groups. There was also no difference in the number of dose changes. The time to reach a therapeutic aPTT was 2 hours shorter in the PDI compared to the PA group, 8 ± 4 hours versus 10 ± 4 hours, P = .015. This study demonstrates a significant time advantage associated with a PDI nomogram compared to a PA nomogram but no difference with respect to the number of rate changes.
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Affiliation(s)
- Paul A. Arpino
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | | | - Anthony Fatalo
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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Heparin-Induced Thrombocytopenia. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00042-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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10
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Kortchinsky T, Vigué B, Samama CM. [Reversal for heparins and new anticoagulant treatments]. ACTA ACUST UNITED AC 2012; 32:37-49. [PMID: 23273505 DOI: 10.1016/j.annfar.2012.10.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 10/23/2012] [Indexed: 11/28/2022]
Abstract
Even with unfractionated heparin or derivates, the reversal of pharmacologic anticoagulation is crucial in anticoagulated patients developing a life-threatening bleeding or scheduled for an emergency procedure. The antagonisation of unfractionated heparin is well codified: each milligram of protamine sulfate antagonizes 100 IU of heparin. Measurement of thrombin time reflects the anti-IIa effect of heparin and has to be monitored immediately and 1hour after the injection of protamine. The required dose of protamine sulfate depends on dosage and time of LMWH administration, although no clinical study supports these data. To date, there is no effective antidote for new anticoagulants (fondaparinux and other pentasaccharides, direct thrombin inhibitors, direct anti-Xa inhibitors). Some preliminary studies suggest the effectiveness of recombinant activated factor VII for pentasaccharides and activated or not Prothrombin Complex Concentrates and recombinant activated factor VII for oral anti-Xa and anti-IIa agents. Therefore, while the characteristics of these new anticoagulants could increase the comfort and improve the compliance, their development needs to ascertain the lack of increase in bleeding complications and the need for a safe and effective antidote.
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Affiliation(s)
- T Kortchinsky
- Centre chirurgical Marie-Lannelongue, réanimation adulte, 92350 Le Plessis-Robinson, France
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Cooper T, White CL, Taber D, Uber WE, Kokko H, Mazur J. Safety and effectiveness outcomes of an inpatient collaborative drug therapy management service for direct thrombin inhibitors. Am J Health Syst Pharm 2012; 69:1993-8. [PMID: 23135566 DOI: 10.2146/ajhp120121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The impact of a collaborative drug therapy management (CDTM) agreement enabling pharmacist-managed direct thrombin inhibitor (DTI) therapy was evaluated. METHODS A retrospective chart review was conducted to compare selected outcome measures between cohorts of adults who received argatroban or bivalirudin therapy for suspected heparin-induced thrombocytopenia (HIT) before (n = 25) and after (n = 25) the implementation of an institutional DTI protocol under which properly trained and credentialed pharmacists have a primary role in dosing and monitoring DTI infusions. The primary endpoints were the mean time to attainment of activated partial thromboplastin time (aPTT) values in a specified therapeutic range and the proportion of total inpatient treatment time during which aPTT values were in that range. Secondary endpoints included the incidence of major and minor bleeding and the incidence of medication errors. RESULTS After implementation of the DTI protocol, therapeutic aPTT values were achieved more rapidly (a mean of 3.4 hours in the postimplementation cohort versus a mean of 7.7 hours in the preimplementation cohort, p = 0.009) and maintained more consistently. Rates of bleeding and overall mortality were similar in the two groups; the frequencies of documented medication errors were 12% and 40% in the postimplementation and preimplementation cohorts, respectively (p = 0.05). CONCLUSION A pharmacist-driven DTI program resulted in improved effectiveness and safety outcomes, as demonstrated by improved attainment of target aPTT values and a decreased frequency of medication errors.
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Affiliation(s)
- Tanna Cooper
- Medical/Surgical Intensive Care Unit, Medical University of South Carolina (MUSC), Charleston, SC 29425, USA.
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Young SK, Riding D, Antonio ME, Al-Mondhiry HA. Efficacy of a Nurse-Managed Argatroban Dose-Adjustment Protocol in a University Teaching Hospital. Hosp Pharm 2012. [DOI: 10.1310/hpj4709-712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Argatroban is a direct thrombin inhibitor used in the treatment of heparin-induced thrombocytopenia (HIT). No study has evaluated the safety and efficacy of a nurse-managed argatroban dosing protocol. Methods We performed a retrospective analysis of 151 total admissions (129 patients) in which argatroban infusions were administered before and after protocol implementation. The preprotocol and postprotocol groups consisted of 69 and 68 admissions, respectively. Patients were eligible for inclusion if they were ≥18 years old and received an argatroban drip for any reason in the 2 years prior to or following protocol implementation. Results There were no statistically significant differences in the incidence of clinically overt bleeding (primary study safety endpoint) between groups. There was no difference between groups in the primary efficacy endpoints, the mean number of partial thromboplastin time (aPTT) assessments per day, and dose adjustments. The mean number of sub- and supratherapeutic aPTTs during treatment was higher in the preprotocol group when utilizing the specified range in the preprotocol group and the protocol's aPTT range (45–90 s); the preprotocol and postprotocol groups had an average of 3.4 and 1.04 subtherapeutic aPTTs, respectively ( P = .008). Similarly, the preprotocol group had an average of 4.98 supratherapeutic aPTTs, while the postprotocol group had 1.84 ( P < .001). There was no difference in duration of argatroban infusion in the preprotocol group compared to the postprotocol group with regard to duration of infusion or final infusion rate. Conclusions This nurse-managed argatroban adjustment protocol provides similar safety and efficacy outcomes and decreased monitoring when pre and post implementation were compared.
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Affiliation(s)
- Sallie K. Young
- Department of Pharmacy, The Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | | | | | - Hamid A. Al-Mondhiry
- Division of Hematology/Oncology, The Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
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Results of a consensus meeting on the use of argatroban in patients with heparin-induced thrombocytopenia requiring antithrombotic therapy - a European Perspective. Thromb Res 2011; 129:426-33. [PMID: 22178575 DOI: 10.1016/j.thromres.2011.11.041] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 11/22/2011] [Accepted: 11/24/2011] [Indexed: 02/07/2023]
Abstract
Argatroban has been introduced as an alternative parenteral anticoagulant for HIT-patients in several European countries in 2005. In 2009 a panel of experts discussed their clinical experience with argatroban balancing risks and benefits of argatroban treatment in managing the highly procoagulant status of HIT-patients. This article summarizes the main conclusions of this round table discussion. An ongoing issue is the appropriate dosing of argatroban in special patient groups. Therefore, dosing recommendations for different HIT-patient groups (ICU patients; non-ICU patients, paediatric patients, and for patients undergoing renal replacement therapies) are summarized in this consensus statement. Because of the strong correlation between argatroban dosing requirements and scores used to characterize the severity of illness (APACHE; SAPS, SOFA) suitable dosing nomograms are given. This consensus statement contributes to clinically relevant information on the appropriate use and monitoring of argatroban based on the current literature, and provides additional information from clinical experience. As the two other approved drugs for HIT, danaparoid and lepirudin are either currently not available due to manufacturing problems (danaparoid) or will be withdrawn from the market in 2012 (lepirudin), this report should guide physicians who have limited experience with argatroban how to use this drug safely in patients with HIT.
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Jeske WP, Fareed J, Hoppensteadt DA, Lewis B, Walenga JM. Pharmacology of argatroban. Expert Rev Hematol 2011; 3:527-39. [PMID: 21083469 DOI: 10.1586/ehm.10.53] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Argatroban is a synthetic, small-molecule direct thrombin inhibitor that is approved in the USA, the EU and Japan for prophylaxis or treatment of thrombosis in patients with heparin-induced thrombocytopenia (HIT), and for anticoagulation of HIT patients undergoing PCI. Argatroban binds reversibly to, and inhibits both soluble and clot-bound thrombin. Argatroban does not generate antibodies, is not susceptible to degradation by proteases and is cleared hepatically. It has a predictable anticoagulant effect and there is a good correlation between dose, plasma concentration and pharmacodynamic effect. Initial clinical studies suggest that further investigations to establish the use of argatroban in ischemic stroke, acute coronary syndrome, hemodialysis, blood oxygenation, off-pump cardiac surgery and other clinical indications are warranted.
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Affiliation(s)
- Walter P Jeske
- Cardiovascular Institute, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL 60153, USA.
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Kiser TH, Mann AM, Trujillo TC, Hassell KL. Evaluation of empiric versus nomogram-based direct thrombin inhibitor management in patients with suspected heparin-induced thrombocytopenia. Am J Hematol 2011; 86:267-72. [PMID: 21328434 DOI: 10.1002/ajh.21955] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 12/01/2010] [Indexed: 11/09/2022]
Abstract
The aim of this study was to evaluate a direct thrombin inhibitor (DTI) titration protocol in patients with suspected HIT. This observational study compared patients treated with argatroban or bivalirudin according to the University of Colorado Hospital DTI titration protocol versus a control group treated prior to protocol implementation. Protocol patients had DTI initial doses based on organ function and fixed dosage adjustments of 10, 25, or 50%. Initial doses and titrations in the control group were made per physician discretion. A total of 130 patients were enrolled: 47 in the protocol group and 83 in the control group (median age 54 years, 63% male, 78% critically ill, and 54% received argatroban). Goal aPTT was achieved with initial DTI dose in 64% of protocol patients and 46% of control patients (P = 0.07). Median (IQR) time to goal aPTT was reduced in the protocol group compared to the control group [5 hr (2-10 hr) vs. 13 hr (6-29 hr); P < 0.0001]. Median time to dose stabilization was 10 hr (6-27 hr) and 22 hr (13-40 hr) in the protocol and control groups, respectively; P < 0.0001. Median number of titrations to goal was 0 (0-1) versus 1 (0-4), respectively; P = 0.02. Median percentage of aPTT values in goal was 67% (41-100%) versus 53% (33-76%), respectively; P = 0.027. The DTI titration protocol shortened time to achieve goal aPTT, reduced time to dose stabilization, decreased the number of titrations required to achieve aPTT goal, and improved the percentage of aPTT values in goal range.
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Affiliation(s)
- Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado, Aurora, Colorado, USA.
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Meddahi S, Samama M. Les inhibiteurs directs de la thrombine, l’hirudine, la bivalirudine, l’argatroban, et le dabigatran etexilate. ACTA ACUST UNITED AC 2011; 36:24-32. [DOI: 10.1016/j.jmv.2010.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 11/08/2010] [Indexed: 11/26/2022]
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Lobo B, Finch CK, Howard-Thompson A, Gillion A. Pharmacist-Managed Direct Thrombin Inhibitor Protocol Improves Care of Patients with Heparin-Induced Thrombocytopenia. Hosp Pharm 2010. [DOI: 10.1310/hpj4509-705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Use of direct-thrombin inhibitors (DTIs) for the management of patients with heparin-induced thrombocytopenia (HIT) is challenging. A pharmacist-managed DTI protocol was implemented to standardize and improve the care of patients with HIT. A background study that compared DTI protocol–treated patients to those who did not receive treatment with the DTI protocol found that significantly more of the DTI protocol–treated patients received care that was consistent with level 1 guidelines from the American College of Chest Physicians (41% vs 0%). Because outcomes were poor regardless of whether the DTI protocol was used, the protocol was revised to require pharmacist implementation and oversight. A follow-up study compared DTI protocol patients from the background study (non-pharmacist-managed) to the pharmacist-managed DTI protocol group. There were significantly fewer dosing errors, improved nursing documentation, and less reexposure to heparin when the pharmacist was responsible for managing the DTI protocol. A trend toward reduced bleeding was noted. The management of patients with HIT is complex, and there are a number of pitfalls that may lead to poor outcomes. DTIs are high-risk medications that require careful dosing and monitoring to minimize risk for adverse drug events. A DTI protocol may improve care of patients with HIT, and pharmacist oversight of DTI use can help to reduce risk for errors and adverse medication events.
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Affiliation(s)
- Bob Lobo
- Department of Pharmaceutical Services, Vanderbilt University Hospital, Nashville, Tennessee
| | - Christopher K. Finch
- Methodist University Hospital, College of Pharmacy, University of Tennessee, Memphis, Tennessee
| | | | - Amanda Gillion
- Department of Pharmacy, Methodist University Hospital, Memphis, Tennessee
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Abstract
Developing dosing management guidelines or protocol approaches to pharmacotherapy can provide several benefits for standardization of care. Frequently, clinicians may need to incorporate multiple influencing factors to individualize management. In some cases, preestablished, standardized approaches may create barriers to individualized care, potentially categorizing patients into dosing categories (silos) that minimize their individualized needs. Approaches to managing direct thrombin inhibitor therapy have been recently explored and dosing approaches different from those provided in the prescribing information have been proposed. Considerations regarding individualized management of anticoagulant therapy, including the use of standardized dosing or monitoring protocols, are discussed here.
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Affiliation(s)
- William E Dager
- William E Dager PharmD BCPS FCSHP FCCP, Pharmacist Specialist, Department of Pharmaceutical Services, University of California, Davis Medical Center, Sacramento, CA; Clinical Professor of Pharmacy, School of Pharmacy, University of California at San Francisco; Clinical Professor of Medicine, School of Medicine, University of California Davis
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