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Kamata M, Sebastian R, McConnell PI, Gomez D, Naguib A, Tobias JD. Perioperative care in an adolescent patient with heparin-induced thrombocytopenia for placement of a cardiac assist device and heart transplantation: case report and literature review. Int Med Case Rep J 2017; 10:55-63. [PMID: 28243155 PMCID: PMC5317301 DOI: 10.2147/imcrj.s118250] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) can cause life-threatening complications following the administration of heparin. Discontinuation of all sources of heparin exposure and the use of alternative agents for anticoagulation are necessary when HIT is suspected or diagnosed. We present the successful use of bivalirudin anticoagulation in an adolescent patient during cardiopulmonary bypass who underwent both placement of a left ventricular assist device and subsequent heart transplantation within a 36-hour period. The pathophysiology and diagnosis of HIT are reviewed, previous reports of the use of direct thrombin inhibitors for cardiac surgery are presented, and potential dosing regimens for bivalirudin are discussed.
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Affiliation(s)
- Mineto Kamata
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital
| | - Roby Sebastian
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine
| | | | - Daniel Gomez
- Cardiovascular Perfusion Services and Heart Center, Nationwide Children's Hospital and The Ohio State University
| | - Aymen Naguib
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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Choo KJL, Simons FER, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. ACTA ACUST UNITED AC 2013; 8:1276-94. [DOI: 10.1002/ebch.1925] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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3
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Interference of thrombin in immunological assays for hirudin specific antibodies. J Immunol Methods 2012; 381:50-8. [DOI: 10.1016/j.jim.2012.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 04/12/2012] [Accepted: 04/12/2012] [Indexed: 10/28/2022]
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4
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Shaikh N, Rahman MA, Nayeemuddin M, Maudali IN, Matthias R, Al Thani H. Heparin-induced Thrombocytopenia: A known rare complication of heparin therapy. Qatar Med J 2012. [DOI: 10.5339/qmj.2012.1.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a rare clinico-pathological abnormality. It is characterized by the development of thrombocytopenia, resulting from heparin administration, which leads to a decrease in platelet count by 50%, or to less than 1 0 0 x 1 0 3 M within 5 to 14 days. HIT causes increased morbidity and mortality, thus it is of vital importance that acute care physicians, surgeons and intensivist should be aware of this clinical entity. We report a case of heparin-induced thrombocytopenia and review of its management, including alternatives to heparin therapy.
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Affiliation(s)
- N. Shaikh
- Department of Anesrthesia/ICU and Pain Management, Hamad Medical Corporation, Doha, Qatar
| | - M. A. Rahman
- Department of Anesrthesia/ICU and Pain Management, Hamad Medical Corporation, Doha, Qatar
| | - M. Nayeemuddin
- Department of Anesrthesia/ICU and Pain Management, Hamad Medical Corporation, Doha, Qatar
| | - I. N. Maudali
- Department of Anesrthesia/ICU and Pain Management, Hamad Medical Corporation, Doha, Qatar
| | - R. Matthias
- Department of Anesrthesia/ICU and Pain Management, Hamad Medical Corporation, Doha, Qatar
| | - H. Al Thani
- Department of Anesrthesia/ICU and Pain Management, Hamad Medical Corporation, Doha, Qatar
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Abstract
BACKGROUND Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may result in death. Anaphylaxis guidelines recommend glucocorticoids for the treatment of people experiencing anaphylaxis. OBJECTIVES We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis. SEARCH METHODS In our previous version we searched the literature until September 2009. In this version we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (Ovid) (1956 to September 2011), EMBASE (Ovid) (1982 to September 2011), CINAHL (EBSCOhost) (to September 2011). We also searched the UK National Research Register and websites listing ongoing trials, and contacted international experts in anaphylaxis in an attempt to locate unpublished material. SELECTION CRITERIA We planned to include randomized and quasi-randomized controlled trials comparing glucocorticoids with any control (either placebo, adrenaline (epinephrine), an antihistamine, or any combination of these). DATA COLLECTION AND ANALYSIS Two authors independently assessed articles for inclusion. MAIN RESULTS We found no studies that satisfied the inclusion criteria. AUTHORS' CONCLUSIONS We are, based on this review, unable to make any recommendations for the use of glucocorticoids in the treatment of anaphylaxis.
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Affiliation(s)
- Karen Jui Lin Choo
- The University of EdinburghAllergy & Respiratory Research Group, Centre for Population Health Sciences: GP SectionDoorway 3, Teviot PlaceEdinburghScotlandUKEH8 9AG
| | - F Estelle R Simons
- Faculty of Medicine, University of ManitobaDepartment of Pediatrics & Child Health; Department of ImmunologyWinnipegMBCanada
| | - Aziz Sheikh
- The University of EdinburghAsthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and InformaticsTeviot PlaceEdinburghUKEH8 9AG
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Shaikh N. Heparin-induced thrombocytopenia. J Emerg Trauma Shock 2011; 4:97-102. [PMID: 21633576 PMCID: PMC3097589 DOI: 10.4103/0974-2700.76843] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 10/12/2010] [Indexed: 11/04/2022] Open
Abstract
In the last 7 decades heparin has remained the most commonly used anticoagulant. Its use is increasing, mainly due to the increase in the number of vascular interventions and aging population. The most feared complication of heparin use is heparin-induced thrombocytopenia (HIT). HIT is a clinicopathologic hypercoagulable, procoagulant prothrombotic condition in patients on heparin therapy, and decrease in platelet count by 50% or to less than 100,000, from 5 to 14 days of therapy. This prothrombotic hypercoagulable state in HIT patient is due to the combined effect of various factors, such as platelet activation, mainly the formation of PF4/heparin/IgG complex, stimulation of the intrinsic factor, and loss of anticoagulant effect of heparin. Diagnosis of HIT is done by clinical condition, heparin use, and timing of thrombocytopenia, and it is confirmed by either serotonin release assay or ELISA assay. Complications of HIT are venous/arterial thrombosis, skin gangrene, and acute platelet activation syndrome. Stopping heparin is the basic initial treatment, and Direct Thrombin Inhibitors (DTI) are medication of choice in these patients. A few routine but essential procedures performed by using heparin are hemodialysis, Percutaneous Coronary Intervention, and Cardiopulmonary Bypass; but it cannot be used if a patient develops HIT. HIT patients with unstable angina, thromboembolism, or indwelling devices, such as valve replacement or intraaortic balloon pump, will require alternative anticoagulation therapy. HIT can be prevented significantly by keeping heparin therapy shorter, avoiding bovine heparin, using low-molecular weight heparin, and stopping heparin use for flush and heparin lock.
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Affiliation(s)
- Nissar Shaikh
- Department of Anaesthesia, ICU and Pain Management, Hamad Medical Corporation, Doha, Qatar
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Abstract
BACKGROUND Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may result in death. A number of guidelines recommend glucocorticoids for the treatment of people experiencing anaphylaxis. OBJECTIVES We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis. METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 3), MEDLINE (Ovid) (1966 to September 2009), EMBASE (Ovid) (1988 to September 2009), CINAHL (EBSCOhost) (to September 2009) and The Science Citation Index Expanded (SCI-EXPANDED) (1945 to September 2009). We also searched the UK National Research Register and websites listing ongoing trials and contacted international experts in anaphylaxis in an attempt to locate unpublished material. We sought to include randomized and quasi-randomized controlled trials comparing glucocorticoids with any control (either placebo, adrenaline (epinephrine), an antihistamine, or any combination of these). Two authors independently assessed articles for inclusion. RESULTS None of the 2496 reports identified satisfied the inclusion criteria. CONCLUSIONS We conclude that there is no evidence from high-quality studies for the use of steroids in the emergency management of anaphylaxis. Therefore, we can neither support nor refute the use of these drugs for this purpose.
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Affiliation(s)
- K J L Choo
- Allergy & Respiratory Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
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Abstract
BACKGROUND Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may result in death. Anaphylaxis guidelines recommend glucocorticoids for the treatment of people experiencing anaphylaxis. OBJECTIVES We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 3), MEDLINE (Ovid) (1966 to September 2009), EMBASE (Ovid) (1988 to September 2009), CINAHL (EBSCOhost) (to September 2009) and The Science Citation Index Expanded (SCI-EXPANDED) (1945 to September 2009). We also searched the UK National Research Register and websites listing ongoing trials, and contacted international experts in anaphylaxis in an attempt to locate unpublished material. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials comparing glucocorticoids with any control (either placebo, adrenaline (epinephrine), an antihistamine, or any combination of these). DATA COLLECTION AND ANALYSIS Two authors independently assessed articles for inclusion. MAIN RESULTS We found no studies that satisfied the inclusion criteria. AUTHORS' CONCLUSIONS We are, based on this review, unable to make any recommendations for the use of glucocorticoids in the treatment of anaphylaxis.
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Affiliation(s)
- Karen Jui Lin Choo
- Primary Care Research & Development, Centre for Population Health Sciences: GP section. The University of Edinburgh, Medical School, Doorway 3, Teviot Place, Edinburgh, UK, EH8 9AG
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Abstract
Heparin-induced thrombocytopenia (HIT) is a clinicopathologic syndrome in which one or more clinical events, usually thrombocytopenia or thrombosis, are temporally related to heparin administration and caused by HIT antibodies. Rapid and accurate diagnosis is essential given the high incidence of thrombosis at around the time of initial disease recognition. Discontinuation of heparin and initiation of alternative anticoagulants reduces HIT-associated morbidity and mortality. The clinical consequences of HIT in hemodialysis patients remain unclear, with several studies reporting no clinical sequelae and others describing complications such as thrombocytopenia or clotting of the extracorporeal circuit. Frequent clotting of the extracorporeal circuit has also been reported in HIT-antibody-positive patients on continuous veno-venous hemofiltration. Several recent findings are of particular interest to nephrologists. An acute systemic reaction has been described as a presentation of HIT in hemodialysis patients shortly after administration of an unfractionated heparin bolus. This syndrome is important to recognize as it might mimic a dialyzer reaction. More recently, the presence of a positive HIT-antibody test or increasing titers of HIT antibody were associated with increased mortality in hemodialysis patients, raising the question of whether these antibodies have a role in the increased cardiovascular mortality seen in these patients. HIT-antibody production is often transient and small numbers of hemodialysis patients with undetectable antibody levels have been rechallenged with heparin without adverse clinical consequences.
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Choo KJL, Simons FER, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Warkentin TE, Greinacher A, Koster A, Lincoff AM. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:340S-380S. [PMID: 18574270 DOI: 10.1378/chest.08-0677] [Citation(s) in RCA: 533] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
This chapter about the recognition, treatment, and prevention of heparin-induced thrombocytopenia (HIT) is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices. Among the key recommendations in this chapter are the following: For patients receiving heparin in whom the clinician considers the risk of HIT to be > 1.0%, we recommend platelet count monitoring over no platelet count monitoring (Grade 1C). For patients who are receiving heparin or have received heparin within the previous 2 weeks, we recommend investigating for a diagnosis of HIT if the platelet count falls by >/= 50%, and/or a thrombotic event occurs, between days 5 and 14 (inclusive) following initiation of heparin, even if the patient is no longer receiving heparin therapy when thrombosis or thrombocytopenia has occurred (Grade 1C). For patients with strongly suspected (or confirmed) HIT, whether or not complicated by thrombosis, we recommend use of an alternative, nonheparin anticoagulant (danaparoid [Grade 1B], lepirudin [Grade 1C], argatroban [Grade 1C], fondaparinux [Grade 2C], or bivalirudin [Grade 2C]) over the further use of unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) therapy or initiation/continuation of vitamin K antagonists (VKAs) [Grade 1B]. The guidelines include specific recommendations for nonheparin anticoagulant dosing that differ from the package inserts. For patients with strongly suspected or confirmed HIT, we recommend against the use of vitamin K antagonist (VKA) [coumarin] therapy until after the platelet count has substantially recovered (usually, to at least 150 x 10(9)/L) over starting VKA therapy at a lower platelet count (Grade 1B); that VKA therapy be started only with low maintenance doses (maximum, 5 mg of warfarin or 6 mg of phenprocoumon) over higher initial doses (Grade 1B); and that the nonheparin anticoagulant (eg, lepirudin, argatroban, danaparoid) be continued until the platelet count has reached a stable plateau, the international normalized ratio (INR) has reached the intended target range, and after a minimum overlap of at least 5 days between nonheparin anticoagulation and VKA therapy rather than a shorter overlap (Grade 1B). For patients receiving VKAs at the time of diagnosis of HIT, we recommend use of vitamin K (10 mg po or 5 to 10 mg IV) [Grade 1C].
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Affiliation(s)
| | - Andreas Greinacher
- Institute for Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University Greifswald, Greifswald, Germany
| | | | - A Michael Lincoff
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, The Cleveland Clinic Foundation, Cleveland, OH
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Gajra A, Husain J, Smith A. Lepirudin in the management of heparin-induced thrombocytopenia. Expert Opin Drug Metab Toxicol 2008; 4:1131-41. [DOI: 10.1517/17425255.4.8.1131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Veach SA, Franks AM, Allan MC. Severe anaphylactic reaction after repeated intermittent exposure to lepirudin. Pharmacotherapy 2007; 27:760-5. [PMID: 17461712 DOI: 10.1592/phco.27.5.760] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Lepirudin, a recombinant DNA derivative of hirudin, is used to prevent thromboembolic complications caused by heparin-induced thrombocytopenia type II. Anaphylactic and anaphylactoid reactions have been reported with its use in patients both with and without known previous exposure to lepirudin. We describe the case of a 57-year-old woman who received five uneventful courses of lepirudin therapy before having a severe anaphylactic reaction during administration of the intravenous bolus dose that began her sixth course. The patient experienced cardiorespiratory arrest but recovered from the reaction. The decision to administer lepirudin to a patient who has previously received it should be reached with due consideration of the risk:benefit ratio and strategies to manage risk resulting from readministration. Risk factors for an anaphylactic reaction to lepirudin may include use of an initial bolus dose, intravenous rather than subcutaneous administration, length of any single course of therapy beyond 3 days, and repeat administration of lepirudin within 100 days.
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Affiliation(s)
- Sidney A Veach
- Department of Pharmacy Practice, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA
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Dager WE, Dougherty JA, Nguyen PH, Militello MA, Smythe MA. Heparin-Induced Thrombocytopenia: Treatment Options and Special Considerations. Pharmacotherapy 2007; 27:564-87. [PMID: 17381384 DOI: 10.1592/phco.27.4.564] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse effect that typically manifests several days after the start of heparin therapy, although both rapid- and delayed-onset HIT have been described. Its most serious complication is thrombosis. Although not all patients develop thrombosis, it can be life threatening. The risk of developing HIT is related to many factors, including the type of heparin product administered, route of administration, duration of therapy, patient population, and previous exposure to heparin. The diagnosis of HIT is typically based on clinical presentation, exposure to heparin, and presence of thrombocytopenia with or without thrombosis. Antigen and activation laboratory assays are available to support the diagnosis of HIT. However, because of the limited sensitivity and specificity of these assays, bedside probability scales for HIT were developed. When HIT is suspected, prompt cessation of all heparin therapy is necessary, along with initiation of alternative anticoagulant therapy. Two direct thrombin inhibitors--argatroban and lepirudin--are approved for the management of HIT in the United States, and bivalirudin is approved for use in patients with HIT who are undergoing percutaneous coronary intervention. Other agents, although not approved to manage HIT, have also been used; however, their role in therapy requires further evaluation. A comprehensive HIT management strategy involves the evaluation of numerous factors. Many patients, including those undergoing coronary artery bypass surgery, those with acute coronary syndromes, those with hepatic or renal insufficiency, and children, require special attention. Clinicians must become familiar with the available information on this serious adverse effect and its treatment so that optimum patient management strategies may be formulated.
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Affiliation(s)
- William E Dager
- Department of Pharmaceutical Services, University of California-Davis Medical Center, California 95817-2201, USA.
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15
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Napolitano LM, Warkentin TE, Almahameed A, Nasraway SA. Heparin-induced thrombocytopenia in the critical care setting: Diagnosis and management^. Crit Care Med 2006; 34:2898-911. [PMID: 17075368 DOI: 10.1097/01.ccm.0000248723.18068.90] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thrombocytopenia is a common occurrence in critical illness, reported in up to 41% of patients. Systematic evaluation of thrombocytopenia in critical care is essential to accurate identification and management of the cause. Although sepsis and hemodilution are more common etiologies of thrombocytopenia in critical illness, heparin-induced thrombocytopenia (HIT) is one potential etiology that warrants consideration. OBJECTIVE This review will summarize the pathogenesis and clinical consequences of HIT, describe the diagnostic process, and review currently available treatment options. DATA SOURCE MEDLINE/PubMed search of all relevant primary and review articles. DATA SYNTHESIS AND CONCLUSIONS HIT is a clinicopathologic syndrome characterized by thrombocytopenia (>/=50% from baseline) that typically occurs between days 5 and 14 after initiation of heparin. This temporal profile suggests a possible diagnosis of HIT, which can be supported (or refuted) with a strong positive (or negative) laboratory test for HIT antibodies. When considering the diagnosis of HIT, critical care professionals should monitor platelet counts in patients who are at risk for HIT and carefully evaluate for, a) temporal features of the thrombocytopenia in relation to heparin exposure; b) severity of thrombocytopenia; c) clinical evidence for thrombosis; and d) alternative etiologies of thrombocytopenia. Due to its prothrombotic nature, early recognition of HIT and prompt substitution of heparin with a direct thrombin inhibitor (e.g., argatroban or lepirudin) or the heparinoid danaparoid (where available) reduces the risk of thromboembolic events, some of which may be life-threatening.
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Affiliation(s)
- Lena M Napolitano
- Acute Care Surgery, Trauma, Burn, Critical Care, Emergency Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
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Pendleton R, Wheeler MM, Rodgers GM. Argatroban Dosing of Patients with Heparin-Induced Thrombocytopenia and an Elevated aPTT Due to Antiphospholipid Antibody Syndrome. Ann Pharmacother 2006; 40:972-6. [PMID: 16569813 DOI: 10.1345/aph.1g319] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe the clinical characteristics, management, and outcomes of patients with heparin-induced thrombocytopenia with thrombosis (HITTS) or without thrombosis (HIT) who also had an elevated baseline activated partial thromboplastin time (aPTT) due to antiphospholipid antibody syndrome (APS). Case Summary: Four patients with HIT/HITTS and an elevated baseline aPTT due to APS were identified. Two patients had venous thrombosis, 1 had limb ischemia, and 1 had isolated HIT. All 4 were managed with a weight-based fixed dose of argatroban without laboratory monitoring. None of the patients had thrombotic or bleeding complications once therapy was initiated. Discussion: Management of patients with HIT/HITTS and an abnormal baseline aPTT due to APS is problematic. We review alternative management strategies, such as monitoring direct thrombin inhibitors with the ecarin clotting time or thrombin inhibition time or using an alternative anticoagulant, such as fondaparinux. As of March 13, 2006, none of these management strategies has been evaluated in a clinical trial for this patient population. We report the successful use of weight-based, fixed-dose argatroban without laboratory monitoring in patients with APS. Conclusions: Use of a fixed-dose argatroban regimen without laboratory monitoring is a potential management strategy for patients with HIT/HITTS and an elevated baseline aPTT due to APS.
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Affiliation(s)
- Robert Pendleton
- University of Utah Medical Center, Salt Lake City, UT 84132-0100, USA
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Abstract
Bivalirudin (Angiomax) is a thrombin-inhibiting oligopeptide that was developed via rational drug design as a hirudin analogue ('hirulog'). Similar to hirudin, it is a bivalent thrombin inhibitor, as its 20-amino acid structure combines a carboxy-terminal region that recognises thrombin's fibrin(ogen)-binding site, and an amino-terminal tetrapeptide that inhibits the active site of thrombin, connected by a tetraglycine spacer. It has certain pharmacological advantages over hirudin, including enzymic metabolism (less dependence on renal clearance) and low immunogenicity (reduced potential for anaphylaxis). Bivalirudin is approved for use in percutaneous transluminal coronary angioplasty (PTCA), and is undergoing active investigation for anticoagulation during cardiac surgery, both 'off-pump' and with cardiopulmonary bypass ('on-pump'). Anecdotal 'off-label' experience for the treatment of heparin-induced thrombocytopenia shows promise.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2005. [DOI: 10.1002/pds.1028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Peitsch WK, Booken D, Velten F, Dempfle CE, Goerdt S, Bayerl C, Utikal J. Hypersensitivity to the pentasaccharide fondaparinux in patients with delayed-type heparin allergy. Thromb Haemost 2005. [DOI: 10.1055/s-0037-1615587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
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