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Alhanshani AA. Heparin Induced Thrombocytopenia - Pathophysiology, Diagnosis and Treatment: A Narrative Review. Int J Gen Med 2023; 16:3947-3953. [PMID: 37667778 PMCID: PMC10475297 DOI: 10.2147/ijgm.s420327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening, immune-mediated complication following heparin exposure and is considered to be the most severe adverse reaction to heparin treatment that is not associated with bleeding. Development of autoantibodies against platelet factor 4 (PF4) - heparin complex constitutes the basis of the pathophysiological changes in patients suffering from HIT, which then binds to the surface of platelets and monocytes, thus provoking their activation and subsequent aggregation, ultimately leading to the formation of thrombosis. Formation of arterial and venous thrombosis is aggravated by the simultaneous activation of platelets and monocytes with a substantial mortality rate. The incidence of HIT is reported to be significantly lower in pediatric patients compared with adults. Diagnosis of HIT in pediatric population remains a clinical entity supplemented by laboratory evaluation. The positive predictive value of laboratory evaluation is further elevated by the use of scoring systems and predictive models used for hastening the diagnosis of HIT. Use of alternative anticoagulants like direct thrombin inhibitors and factor Xa inhibitors form the mainstay of treatment in cases of HIT, however, more prospective studies would be required in the pediatric population to delineate definitive guidelines for proper management of patients in this age-group. This article delivers diagnostic and treatment approach in case of patients with HIT, wherein the pathophysiology, clinical manifestations, diagnostic approach and the management of patients with HIT has been described.
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Affiliation(s)
- Ahmad A Alhanshani
- Department of Child Health, College of Medicine, King Khalid University, Abha, Saudi Arabia
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2
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Dager WE, Walker EA, Roberts AJ. Bivalirudin in Extracorporeal Life Support: Response and Considerations. ASAIO J 2019; 65:e54. [DOI: 10.1097/mat.0000000000000892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Bain J, Flannery AH, Flynn J, Dager W. Heparin induced thrombocytopenia with mechanical circulatory support devices: review of the literature and management considerations. J Thromb Thrombolysis 2017; 44:76-87. [DOI: 10.1007/s11239-017-1494-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Chen LD, Roberts AJ, Dager WE. Safety and efficacy of starting warfarin after two consecutive platelet count rises in heparin-induced thrombocytopenia. Thromb Res 2016; 144:229-33. [PMID: 27241355 DOI: 10.1016/j.thromres.2016.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 05/18/2016] [Accepted: 05/19/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Current guidelines on the treatment of heparin-induced thrombocytopenia (HIT) recommend warfarin initiation when platelet levels recover to 150×10(9)/L or more. However, many patients may not achieve this platelet level or may have slow platelet recovery. The aim of this study is to determine if initiating warfarin when platelets start trending upward instead of at a specific level is safe and effective in patients diagnosed with HIT. MATERIALS AND METHODS Two groups of patients diagnosed and treated for HIT in a tertiary care hospital were assessed for HIT-related outcomes: 28 patients had warfarin initiated after platelets recovered to 150×10(9)/L or more and 30 patients had warfarin initiated prior to platelet recovery. RESULTS There was no significant difference between the rate of thrombosis, venous limb gangrene, or limb amputation. Three patients died during the data collection period, all deemed to be unrelated to HIT by independent investigators. The average hospital length of stay was 22.2±12.7days and 38.8±19.1days for patients who started warfarin at platelets less than 150×10(9)/L and platelets greater than or equal to 150×10(9)/L respectively (P=0.0002). CONCLUSIONS The data suggests that the absolute platelet level at which warfarin is initiated does not affect the rate of thrombosis or mortality but may shorten overall hospital length of stay and associated costs. Therefore, it may be more important to observe an upward trend in platelets rather than striving to achieve an absolute platelet level before starting warfarin in patients with HIT.
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Affiliation(s)
- Lydia D Chen
- Department of Pharmacy, University of California Davis Medical Center, United States
| | - A Josh Roberts
- Department of Pharmacy, University of California Davis Medical Center, United States
| | - William E Dager
- Department of Pharmacy, University of California Davis Medical Center, United States.
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Weintraub L, Driscoll C, Aydin S, Lamour JM, Weinstein S, Manwani D. Challenging diagnosis and treatment of HIT in child with ventricular assistance device. Pediatr Transplant 2015; 19:E152-6. [PMID: 26087151 DOI: 10.1111/petr.12540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2015] [Indexed: 11/28/2022]
Abstract
HIT presents the clinician with unique diagnostic challenges, especially in the pediatric population. The HIT clinical sequelae of thrombocytopenia and thrombosis are secondary to the activation of platelets by heparin-antibody complexes. Diagnosis involves clinical observations and confirmatory laboratory testing using antibody detection and the functional SRA. As we describe in the following case of a six-yr-old female, the SRA may be difficult to interpret in the case of high-titer antibodies and illustrates the need for repeat testing in cases of high clinical suspicion.
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Affiliation(s)
- Lauren Weintraub
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Catherine Driscoll
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Scott Aydin
- Division of Cardiology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jaqueline M Lamour
- Division of Cardiology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sam Weinstein
- Department of Cardiovascular and Thoracic Surgery, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Deepa Manwani
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
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Abstract
In the setting of end-stage kidney disease, the incidence and risk for thrombotic events are increased and use of anticoagulants is common. The incidence of bleeding, however, is also a frequent issue and creates additional challenges in the management of anticoagulation therapy. Patients with end-stage renal disease are typically excluded from large clinical trials exploring the use of anticoagulants, which limits our knowledge of optimal management approaches. Furthermore, varying degrees of renal failure in addition to conditions that alter the pharmacokinetics of various anticoagulants or pharmacodynamic response may warrant alternative approaches to dosing. This review will explore systemic chronic anticoagulation therapy in the setting of chronic kidney disease where hemodialysis is required. Agents discussed include vitamin K antagonists, low-molecular-weight heparins, fondaparinux, oral factor Xa antagonists, and direct thrombin inhibitors. Clinical challenges, approaches to dosing regimens, and tools for measuring responses and reversal will be explored.
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Affiliation(s)
- William E Dager
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California.,Departments of Medicine and Pharmaceutical Services, Davis Medical Center, University of California Davis School of Medicine, Sacramento, California.,Department of Pharmacy, Touro Vallejo School of Pharmacy, Vallejo, California
| | - Laura V Tsu
- Department of Pharmacy Practice, Midwestern College of Pharmacy, Glendale, Arizona
| | - Tiffany K Pon
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, California
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Giant Left Ventricular Thrombus Formation Associated With Heparin-Induced Thrombocytopenia. Ann Thorac Surg 2014; 98:e143-5. [DOI: 10.1016/j.athoracsur.2014.08.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 07/31/2014] [Accepted: 08/08/2014] [Indexed: 11/23/2022]
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Graidis C, Golias C, Dimitriadis D, Dimitriadis G, Bitsis T, Dimitrelos I, Tsiakou A, Charalabopoulos K. Eptifibatide-induced acute profound thrombocytopenia: a case report. BMC Res Notes 2014; 7:107. [PMID: 24564943 PMCID: PMC3996044 DOI: 10.1186/1756-0500-7-107] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 02/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The interactions among cells or among cells and components of the extracellular matrix, is a crucial pathophysiological process involving some molecules collectively known as adhesion molecules (CAMs). Glycoprotein IIb / IIIa receptors are only restricted to blood platelets and they bind fibrinogen and adhesion proteins such as fibronectin, vitronectin, von Willebrand factor to form cross bridges between adjacent platelets. IIb/IIIa receptor antagonists are an object of intense research activity for target therapy worldwide during the last decades. Three GPIIb/IIIa inhibitors, abciximab, tirofiban, and eptifibatide, have been approved for clinical use. Profound thrombocytopenia is an uncommon but clinically important complication of glycoprotein IIb/IIIa inhibitors. CASE PRESENTATION This case report discusses a forty-four-year-old male patient with acute coronary syndrome who underwent percutaneous coronary intervention and developed profound thrombocytopenia within 4 hours of first administration of eptifibatide. CONCLUSION This report adds another case of eptifibatide-induced thrombocytopenia to the medical literature and endorses the importance of platelet count monitoring after initiating therapy with this agent.
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Affiliation(s)
| | | | | | | | | | | | | | - Konstantinos Charalabopoulos
- Department of Physiology, Clinical Unit, Medical Faculty, Democritus University of Thrace, Alexandroupolis 68100, GR, Greece.
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Kounis NG, Kounis GN, Kouni SN, Soufras GD. Allergy to Heparins, Thrombosis, Thrombocytopaenia and Kounis Syndrome: A Clinical Paradox. Heart Lung Circ 2014; 23:103-4. [DOI: 10.1016/j.hlc.2013.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 06/10/2013] [Accepted: 11/01/2013] [Indexed: 10/26/2022]
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10
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Wade WE, Spruill WJ. Fondaparinux sodium in the prophylaxis and treatment of deep vein thrombosis and pulmonary embolism. Expert Rev Pharmacoecon Outcomes Res 2014; 7:227-37. [DOI: 10.1586/14737167.7.3.227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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11
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Hanatani T, Sai K, Tohkin M, Segawa K, Kimura M, Hori K, Kawakami J, Saito Y. An algorithm for the identification of heparin-induced thrombocytopenia using a medical information database. J Clin Pharm Ther 2013; 38:423-8. [DOI: 10.1111/jcpt.12083] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 06/12/2013] [Indexed: 01/24/2023]
Affiliation(s)
- T. Hanatani
- Division of Medicinal Safety Science; National Institute of Health Sciences; Tokyo Japan
- Department of Regulatory Science; Graduate School of Pharmaceutical Sciences; Nagoya City University; Aichi Japan
| | - K. Sai
- Division of Medicinal Safety Science; National Institute of Health Sciences; Tokyo Japan
| | - M. Tohkin
- Department of Regulatory Science; Graduate School of Pharmaceutical Sciences; Nagoya City University; Aichi Japan
| | - K. Segawa
- Division of Medicinal Safety Science; National Institute of Health Sciences; Tokyo Japan
| | - M. Kimura
- Department of Medical Informatics; Hamamatsu University School of Medicine; Shizuoka Japan
| | - K. Hori
- Department of Hospital Pharmacy; Hamamatsu University School of Medicine; Shizuoka Japan
| | - J. Kawakami
- Department of Hospital Pharmacy; Hamamatsu University School of Medicine; Shizuoka Japan
| | - Y. Saito
- Division of Medicinal Safety Science; National Institute of Health Sciences; Tokyo Japan
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Alquwaizani M, Buckley L, Adams C, Fanikos J. Anticoagulants: A Review of the Pharmacology, Dosing, and Complications. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013; 1:83-97. [PMID: 23687625 PMCID: PMC3654192 DOI: 10.1007/s40138-013-0014-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Anticoagulants remain the primary strategy for the prevention and treatment of thrombosis. Unfractionated heparin, low molecular weight heparin, fondaparinux, and warfarin have been studied and employed extensively with direct thrombin inhibitors typically reserved for patients with complications or those requiring intervention. Novel oral anticoagulants have emerged from clinical development and are expected to replace older agents with their ease of use and more favorable pharmacodynamic profiles. Hemorrhage is the main concerning adverse event with all anticoagulants. With their ubiquitous use, it becomes important for clinicians to have a sound understanding of anticoagulant pharmacology, dosing, and toxicity.
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Affiliation(s)
- Mohammed Alquwaizani
- Pharmacy Department, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Leo Buckley
- Pharmacy Department, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Christopher Adams
- Pharmacy Department, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - John Fanikos
- Pharmacy Department, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
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Abstract
OBJECTIVE Anticoagulation with heparin is standard of care for patients maintained on extracorporeal life support. Very limited evidence exists for the use of alternative anticoagulants during extracorporeal life support. Patients with heparin-induced thrombocytopenia, heparin resistance, and evidence of significant thrombosis while on heparin may be candidates for alternative anticoagulation. The objective of this analysis is to present evidence for the use of bivalirudin during extracorporeal life support in pediatric patients. DESIGN Case series. SETTING University of California, Davis Medical Center. PATIENTS Twelve critically ill, pediatric patients receiving bivalirudin for anticoagulation during extracorporeal life support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twelve patients meeting entry criteria received bivalirudin during the study period. The median patient age was 8 days (range, 1 d to 6 yr). Eight patients were neonates. Eight patients were male. Nine patients were supported with venoarterial extracorporeal life support. Median duration of extracorporeal life support was 226 hours (range, 111-913) and median time on bivalirudin was 92 hours (range, 60-230). Bivalirudin bolus doses were administered to select patients without bleeding complications. The maintenance dose that corresponded with initial target activated partial thromboplastin time ranged from 0.045 to 0.48 mg/kg/hr with a median rate of 0.16 mg/kg/hr. The median dose for days 1, 3, and 5 was 0.135, 0.175, and 0.267 mg/kg/hr, respectively. The correlation (r2) between dose adjustment and activated partial thromboplastin time response was 0.264. CONCLUSIONS This is the largest case series describing the use of a direct thrombin inhibitor in pediatric extracorporeal life support patients. The maintenance dose range reflected considerable inter-patient variability. There was an observed increase in dose requirements with time. Bivalirudin, with close monitoring, is a potential option for pediatric patients on extracorporeal life support who have developed heparin-induced thrombocytopenia, heparin resistance, or significant thrombosis while on heparin.
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Wanat MA, Hart SR, Putney D, Liebl MG, Chandler W. Alternative Monitoring of Argatroban Using Plasma-Diluted Thrombin Time. Ann Pharmacother 2013; 47:e18. [DOI: 10.1345/aph.1r644] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of heparin-induced thrombocytopenia (HIT) in a patient with concurrent liver dysfunction and a prolonged baseline activated partial thromboplastin time (aPTT) in whom argatroban therapy was monitored with aPTT and a novel plasma-diluted thrombin assay. CASE SUMMARY An 80-year-old man with HIT and liver dysfunction was treated with argatroban, which was initiated at a dose of 0.5 μg/kg/min and gradually decreased to 0.09 μg/kg/min. The patient had a mildly prolonged aPTT at baseline (37.5 seconds). He was concurrently monitored with aPTT, per institution protocol, and plasma-diluted thrombin time. Plasma-diluted thrombin times were consistently lower than aPTTs, but mirrored the trend of the aPTTs. Eleven hours after argatroban was stopped, the aPTT remained elevated (53.9 seconds), while the plasma-diluted thrombin time returned to normal range (26.4 seconds). The patient's therapy was transitioned to warfarin and he had a hospital course with no thrombotic or bleeding complications. DISCUSSION Plasma-diluted thrombin time is a novel laboratory test consisting of 1 part patient plasma diluted with 3 parts normal plasma. Plasma-diluted thrombin time has been shown to blunt the sensitivity of the thrombin time and may be more accurate for drug monitoring. A MEDLINE search revealed 2 studies using the plasma-diluted thrombin time assay. The first study compared aPTT and plasma-diluted thrombin times in blood samples mixed with argatroban, bivalirudin, or lepirudin at 3 different concentrations. Blood samples contained lupus inhibitors, vitamin k deficiency, or normal baseline aPTTs. The aPTT overestimated drug concentrations in all samples with lupus anticoagulant and vitamin k deficiency, while the plasma-diluted thrombin time correctly estimated drug concentrations in nearly all samples. The second study looked at monitoring dabigatran with plasma-diluted thrombin time and found a linear relationship between the plasma-diluted thrombin time and the dabigatran dose-response curve. CONCLUSIONS Plasma-diluted thrombin time may be an alternative for direct thrombin inhibitor monitoring in patients with elevated aPTT values at baseline. Further randomized control trials are needed to determine its applicability in clinical practice.
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Affiliation(s)
- Matthew A Wanat
- Matthew A Wanat PharmD BCPS, Clinical Assistant Professor, College of Pharmacy, University of Houston, Houston, TX
| | - Sara R Hart
- Sara R Hart PharmD BCPS, Clinical Pharmacy Specialist, Department of Pharmacy, The Methodist Hospital, Houston
| | - David Putney
- David Putney PharmD BCPS AQ-Cardiology, Clinical Pharmacy Specialist, Department of Pharmacy, The Methodist Hospital
| | - Michael G Liebl
- Michael G Liebl PharmD BCPS, Clinical Pharmacy Manager, Department of Pharmacy, The Methodist Hospital
| | - Wayne Chandler
- Wayne Chandler MD, Medical Director, Coagulation Laboratory, Deparment of Pathology and Genomic Medicine, The Methodist Hospital Physician Organization, Houston
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Tsu LV, Dager WE. Comparison of bivalirudin dosing strategies using total, adjusted, and ideal body weights in obese patients with heparin-induced thrombocytopenia. Pharmacotherapy 2012; 32:20-6. [PMID: 22392825 DOI: 10.1002/phar.1016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVES To compare dosing strategies using total body weight (actual measured body weight), adjusted body weight, and ideal body weight when starting bivalirudin for the treatment for heparin-induced thrombocytopenia (HIT) in obese patients, and to compare differences in dosing requirements and clinical outcomes between obese and nonobese patients. DESIGN Retrospective medical record review. SETTING Academic tertiary care medical center. PATIENTS One hundred thirty-five medical and surgical patients who were treated with bivalirudin for HIT between June 1, 2004, and October 1, 2009. MEASUREMENTS AND MAIN RESULTS The 135 patients were separated into two groups based on body mass index (BMI): 46 patients had a BMI greater than 30 kg/m(2) and were classified in the obese group; the nonobese group consisted of 89 patients with a BMI less than 30 kg/m(2) . The mean BMI in the obese group was 37.7 kg/m(2) (range: 30.1-56.2 kg/m(2) ). Weight-standardized doses that achieved activated partial thromboplastin time (aPTT) goal were compared in the obese group. The mean ± SD doses that achieved aPTT goal with total (actual), adjusted, and ideal body weights in this group were 0.1 ± 0.07, 0.11 ± 0.08, and 0.14 ± 0.09 mg/kg/hour, respectively. Of the three weight-based dosing approaches, total body weight followed by adjusted body weight provided the closest correlation to rates observed at the target aPTT goal. The secondary analysis compared initial doses of bivalirudin, doses required to reach goal aPTT, time to achieve goal aPTT, and clinical outcomes (number of patients not achieving goal, new thrombosis, major bleeding, and 30-day all-cause mortality) between the obese and nonobese groups. A significant difference in initial dose was noted between groups; however, no significant differences in dose required to achieve goal aPTT, time to achieve goal aPTT, and clinical outcomes were noted between the obese and nonobese groups. CONCLUSION This study provides evidence that the dosing strategy for bivalirudin based on total body weight is the most accurate predictor of achieving aPTT goal in obese patients with HIT. The study also suggests that there are no clinical differences that warrant different dosing strategies between obese and nonobese patients. Further prospective studies are needed to confirm these findings.
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Affiliation(s)
- Laura V Tsu
- Department of Pharmaceutical Services, University of California Davis Medical Center, Sacramento, California 95817-2201, USA
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Curvers J, van de Kerkhof D, Stroobants AK, van den Dool EJ, Scharnhorst V. Measuring direct thrombin inhibitors with routine and dedicated coagulation assays: which assay is helpful? Am J Clin Pathol 2012; 138:551-8. [PMID: 23010710 DOI: 10.1309/ajcpqod9wfpeyy0h] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The use of direct thrombin inhibitors (DTIs) for prophylactic or therapeutic anticoagulation is increasing because of the predictable bioavailability and short half-life of these DTIs. However, in certain situations, indication of the concentration is warranted. We investigated the effects of 3 DTIs (lepirudin, argatroban, and bivalirudin) in 6 pooled plasma specimens on routine coagulation assays (activated partial thromboplastin time [aPTT], prothrombin time [PT], and thrombin time [TT]) and dedicated DTI assays (Hemoclot, HemosIL, the ecarin clotting time, and a chromogenic ecarin clotting time) on 2 coagulation analyzers. We found routine tests to be nondiscriminative between concentrations of different DTIs in the aPTT. Moreover, for PT and TT, the responses for different DTIs differed. This was similar for ecarin clotting assays. The Hemoclot and HemosIL assays showed identical linear increases for all 3 DTIs. We conclude that dedicated calibrated assays based on a diluted TT (Hemoclot and HemosIL) appear to be the most suitable for monitoring purposes.
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Affiliation(s)
- Joyce Curvers
- Clinical Laboratory, Catharina Hospital, Eindhoven, the Netherlands
| | | | - An K. Stroobants
- Laboratory for General Clinical Chemistry, Academic Medical Center, Amsterdam, the Netherlands
| | - Erik-Jan van den Dool
- Laboratory for General Clinical Chemistry, Academic Medical Center, Amsterdam, the Netherlands
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Cohen RA, Castellano M, Garcia CA. Heparin induced thrombocytopenia: case presentation and review. J Clin Med Res 2012; 4:68-72. [PMID: 22383932 PMCID: PMC3279506 DOI: 10.4021/jocmr751w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2011] [Indexed: 11/05/2022] Open
Abstract
Heparin Induced Thrombocytopenia (HIT) is an adverse effect of heparin therapy with possibly devastating consequences. We present a case of HIT Type II. An in-depth review of HIT is presented, examining the important clinical symptoms and diagnostic indicators. The treatment of HIT is then discussed, with an emphasis on current therapies. An extensive literature review has been performed to present a comprehensive review of the causes, pathophysiology and treatment of HIT.
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Affiliation(s)
- Ronny A Cohen
- Woodhull Medical Center, NYU School of Medicine, Brooklyn, NY, USA
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18
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Vakil NH, Kanaan AO, Donovan JL. Heparin-induced thrombocytopenia in the pediatric population: a review of current literature. J Pediatr Pharmacol Ther 2012; 17:12-30. [PMID: 23118656 PMCID: PMC3428184 DOI: 10.5863/1551-6776-17.1.12] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Heparin-induced thrombocytopenia is a rare and serious reaction to unfractionated heparin and low-molecular-weight heparins in children. Quick recognition, discontinuation of heparin, and subsequent treatment with an alternative anticoagulant are essential steps to prevent serious complications such as thrombus and limb amputation. The purpose of this review is to describe the clinical features of heparin-induced thrombocytopenia in children and to summarize the data available for its management. This paper summarizes data and relates the use of direct thrombin inhibitors with clinical outcomes. A literature search was conducted with Ovid, using the key terms argatroban, bivalirudin, hirulog, danaparoid, lepirudin, direct thrombin inhibitor, heparin-induced thrombocytopenia, thrombosis, warfarin, and fondaparinux. Articles were excluded if they were classified as editorials, review articles, or conference abstracts or if they involved patients 18 years of age or older or described disease states not related to thrombosis. Nineteen articles containing 33 case reports were identified and evaluated for this review. Of the 33 cases, 14, 10, 4, and 2 cases described the use of lepirudin, danaparoid, argatroban, and bivalirudin, respectively. Two cases did not report the type of anticoagulant used, and 1 case used aspirin. The most commonly reported complication was bleeding.
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Affiliation(s)
- Niyati H. Vakil
- Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
| | - Abir O. Kanaan
- Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
| | - Jennifer L. Donovan
- Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
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Runyan CL, Cabral KP, Riker RR, Redding D, May T, Seder DB, Savic M, Hedlund J, Abramson S, Fraser GL. Correlation of Bivalirudin Dose with Creatinine Clearance During Treatment of Heparin-Induced Thrombocytopenia. Pharmacotherapy 2011; 31:850-6. [DOI: 10.1592/phco.31.9.850] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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20
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Tsu LV, Dager WE. Bivalirudin dosing adjustments for reduced renal function with or without hemodialysis in the management of heparin-induced thrombocytopenia. Ann Pharmacother 2011; 45:1185-92. [PMID: 21881032 DOI: 10.1345/aph.1q177] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND While not approved by the Food and Drug Administration for treatment of heparin-induced thrombocytopenia (HIT), except in patients undergoing percutaneous interventions, the direct thrombin inhibitor bivalirudin is a treatment option that is gaining use. An initial dose of bivalirudin 0.15-0.2 mg/kg/h, adjusted to an activated partial thromboplastin time (aPTT) of 1.5-2.5 times the baseline value, has been suggested. Initial dosing in patients with renal dysfunction, including those on hemodialysis, is unclear. OBJECTIVE To evaluate initial bivalirudin dosing requirements in patients with and without renal dysfunction, including patients on different forms of dialysis. METHODS A retrospective analysis of 135 patients treated with bivalirudin for HIT between June 2004 and October 2009 was conducted at a tertiary care medical center. The patients were divided into groups, based on renal function. Patients receiving dialysis were divided into 3 subgroups based on the mode of hemodialysis: intermittent hemodialysis (IHD, n = 24), sustained low-efficiency daily diafiltration (SLEDD, n = 12), or continuous renal replacement therapy (CRRT, n = 5). Patients not receiving dialysis were separated into 3 subgroups based on calculated creatinine clearance (CrCl): CrCl >60 mL/min (n = 52), CrCl 30-60 mL/min (n = 26), and CrCl <30 mL/min (n = 16). RESULTS Compared with patients with normal renal function (CrCl >60 mL/min), patients with differing degrees of renal dysfunction (CrCl 30-60 and <30 mL/min) required lower doses of bivalirudin to achieve aPTT goal (0.13 vs 0.08 vs 0.05 mg/kg/h, respectively; p < 0.001). Patients on dialysis (IHD, SLEDD, CRRT) also required dose reductions (0.07, 0.09, and 0.07 mg/kg/h) compared with patients with normal renal function, but higher dosing requirements than patients not receiving dialysis with CrCl <30 mL/min. CONCLUSIONS Patients with renal dysfunction require a reduced dose of bivalirudin to reach a therapeutic aPTT goal. Slightly higher doses may be observed in patients receiving hemodialysis.
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Affiliation(s)
- Laura V Tsu
- Davis Medical Center, University of California, Sacramento, CA, USA
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Greinacher A, Warkentin TE. Risk of heparin-induced thrombocytopenia in patients receiving thromboprophylaxis. Expert Rev Hematol 2011; 1:75-85. [PMID: 21083008 DOI: 10.1586/17474086.1.1.75] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a clinicopathological syndrome associated with heparin therapy that is characterized by a decrease in platelet counts and/or the development of a new thrombosis. Two types of HIT exist, type I is nonimmune and self-resolves, whereas type II is immune-mediated and clinically important. The formation of antibodies against the platelet factor 4-heparin complexes results in platelet activation and thrombin formation, which lead to an increased risk of thrombosis. Unfractionated heparin is associated with a higher risk of HIT than low-molecular-weight heparins. Surgical patients, particularly those undergoing orthopedic or cardiac surgery, are at higher risk of HIT than medical patients. Treatment of HIT involves heparin cessation together with anticoagulation with direct thrombin inhibitors or indirect factor Xa inhibitors.
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Affiliation(s)
- Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Sauerbruchstraße, 17487 Greifswald, Germany.
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22
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Lee YK, Player MR. Developments in factor Xa inhibitors for the treatment of thromboembolic disorders. Med Res Rev 2011; 31:202-83. [DOI: 10.1002/med.20183] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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23
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24
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Dager WE, Kiser TH. Systemic anticoagulation considerations in chronic kidney disease. Adv Chronic Kidney Dis 2010; 17:420-7. [PMID: 20727512 DOI: 10.1053/j.ackd.2010.06.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 05/20/2010] [Accepted: 06/10/2010] [Indexed: 11/11/2022]
Abstract
Anticoagulation therapy is commonly required in patients with chronic kidney disease for treatment or prevention of thromboembolic disorders. Anticoagulant management plans can involve use of a single agent, or in some cases, a combination of agents to meet both short- and long-term goals. Systemic anticoagulation in the setting of renal insufficiency poses unique challenges secondary to renal failure-associated hypercoagulable conditions and increased risks for bleeding. Evidence supporting dosing regimens and monitoring approaches in the setting of severe renal impairment or hemodialysis is limited because this population is typically excluded in clinical trials. This review explores concepts of systemic anticoagulation in the chronic kidney disease setting with warfarin, unfractionated heparin, low-molecular-weight heparin, fondaparinux, direct thrombin inhibitors, and anticoagulants in advanced stages of development. Potential strategies for anticoagulant reversal are also briefly described.
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Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug reaction to heparin products leading to a prothrombotic state. Devastating clinical sequelae may result, including venous or arterial thromboembolism, limb amputation, and death. Heparin cessation alone is insufficient to manage HIT. Pharmacotherapy with argatroban or lepirudin is essential. This article reviews the pathogenesis, diagnosis, and pharmacotherapy of HIT.
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Affiliation(s)
- Jennifer L. Donovan
- Massachusetts College of Pharmacy and Health Sciences, Worcester, MA, USA
- Department of Pharmacy, UMass Memorial Medical Center, Worcester, MA, USA
| | - Maichi T. Tran
- Department of Pharmacy, UMass Memorial Medical Center, Worcester, MA, USA
| | - Abir O. Kanaan
- Massachusetts College of Pharmacy and Health Sciences, Worcester, MA, USA
- Department of Pharmacy, St. Vincent Hospital, Worcester, MA, USA
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Maurer SH, Wilimas JA, Wang WC, Reiss UM. Heparin induced thrombocytopenia and re-thrombosis associated with warfarin and fondaparinux in a child. Pediatr Blood Cancer 2009; 53:468-71. [PMID: 19415734 PMCID: PMC4778081 DOI: 10.1002/pbc.22067] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An 11-year-old female developed heparin induced thrombocytopenia (HIT) with thrombosis during therapy for lower extremity deep vein thrombosis and pulmonary embolism. Transition from bivalirudin, a direct thrombin inhibitor (DTI), to warfarin resulted in extensive re-thrombosis, and fondaparinux therapy similarly failed. She was then treated with argatroban, and transitioned successfully to warfarin after 9 weeks. The risk of re-thrombosis was ultimately reduced by allowing time for the thrombogenic potential to abate. The argatroban/warfarin transition was monitored with chromogenic factor X levels. This case highlights several difficult problems in pediatric thrombosis.
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Affiliation(s)
- Scott H. Maurer
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN
| | - Judith A. Wilimas
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN
| | - Winfred C. Wang
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN
| | - Ulrike M. Reiss
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, TN
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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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Russell KN, Schnabel JG, Rochetto RP, Tanner MC. Acute Profound Thrombocytopenia Associated with Readministration of Eptifibatide: Case Report and Review of the Literature. Pharmacotherapy 2009; 29:867-74. [DOI: 10.1592/phco.29.7.867] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bates D. Clinical experience with argatroban for heparin-induced thrombocytopenia in a large teaching hospital. Can J Hosp Pharm 2009; 62:290-7. [PMID: 22478907 PMCID: PMC2826966 DOI: 10.4212/cjhp.v62i4.810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Argatroban is a direct thrombin inhibitor approved for the prophylaxis or treatment of thrombosis in patients with heparin-induced thrombocytopenia (HIT). The product monograph does not guide clinicians beyond specifying the initial dose of 2 μg/kg per minute (or 0.5 μg/kg per minute for patients with hepatic impairment). Some authors have suggested that in the intensive care unit (ICU) and for patients with acute cardiac disease and those with renal or hepatic dysfunction, this dose may result in a supratherapeutic activated partial thromboplastin time (aPTT). OBJECTIVES To evaluate the efficacy and safety of argatroban in adult patients with suspected HIT in a large teaching hospital, and to review dosing for patients in the ICU, patients with acute cardiac disease, and patients with renal or hepatic dysfunction. METHODS Charts of patients with suspected HIT who had received argatroban for at least 24 h between October 1, 2005, and October 1, 2007, at the Foothills Medical Centre, Calgary, Alberta, were examined retrospectively. RESULTS Thirty patients met the inclusion criteria, with charts available for review. Of these, 21 (70%) patients had an initial argatroban dose of 2 μg/kg per minute and 4 (13%) had an initial dose of 0.5 μg/kg per minute. The median duration of therapy was 6 days, and the mean dose was 2.14 μg/kg per minute. There were 122 dosage adjustments, the most common change being 0.5 μg/kg per minute, followed by adjustments of 1 and 0.1 μg/kg per minute. Six patients had supratherapeutic aPTT values (above 100 s), and none experienced major bleeding. CONCLUSIONS The results of this study suggest that an initial argatroban dose of 2 μg/kg per minute is appropriate for patients with no hepatic dysfunction. Patients with acute cardiac disease and critically ill patients may require lower doses of argatroban; however no dosage adjustments are required for patients with renal dysfunction.
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Affiliation(s)
- Duane Bates
- Duane Bates, BScPharm, ACPR, is Clinical Practice Leader, Medicine in the Department of Pharmacy, Peter Lougheed Centre, Calgary, Alberta
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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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31
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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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32
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Wetz RC, Stroup JS, Roberts ML. Phlegmasia Cerulea Dolens in a Patient with Heparin-Induced Thrombocytopenia. J Pharm Technol 2008. [DOI: 10.1177/875512250802400306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To report a case of the venous obstructive condition known as phlegmasia cerulea dolens (PCD) in the presence of heparin-induced thrombocytopenia (HIT). Case Summary: A 50-year-old white female presented to the emergency department with a 2-day history of a bluish discoloration of her toes and hands accompanied by chest pain and shortness of breath. The evident edema, tenderness on palpation, and cyanosis of the extremities were suggestive of PCD. She had been hospitalized approximately one month previously due to a fibular fracture and again within the past 2 weeks for intractable abdominal pain and nausea. During her current hospital stay, she was diagnosed with multiple venous thromboembolisms (VTEs); at the time of admission, an unfractionated heparin (UFH) drip was initiated to treat her VTEs. Due to a decreased platelet count on admission, a platelet factor 4 (PF4) antibody assay was performed and found to be positive. After discontinuation of UFH, her platelet count slowly returned to normal range. Discussion: The pathogenesis of HIT is due to formation of antibodies against the complex of heparin and PF4. HIT is characterized by a reduction in the platelet count approximately 4–14 days after the initiation of heparin therapy plus a paradoxical prothrombotic state. The typical diagnostic clues are a drop in platelet count of 50% from baseline with the initiation of heparin and a positive assay for heparin-PF4-immunoglobulin G. This condition may result in PCD, which presents as the triad of pain, edema, and cyanosis. This condition often results in venous or arterial thrombus formation. The treatment for PCD includes immediate discontinuation of heparin products and anticoagulation with a direct thrombin inhibitor. Conclusions: Thromboembolic complications such as PCD are often observed as a presenting feature of HIT. To avoid these potentially limb- and life-threatening complications, clinicians must be vigilant in their monitoring of platelets and clinical signs and symptoms of HIT while patients are on heparin therapy.
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Affiliation(s)
- R Colin Wetz
- R COLIN WETZ DO, Internal Medicine Resident, Oklahoma State University Medical Center, Tulsa, OK
| | - Jeffrey S Stroup
- JEFFREY S STROUP PharmD BCPS, Assistant Professor of Medicine, Oklahoma State University Center for Health Sciences, Tulsa
| | - Montgomery L Roberts
- MONTGOMERY L ROBERTS DO, Assistant Professor of Medicine, Oklahoma State University Center for Health Sciences
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34
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Dager WE. Considerations for Drug Dosing Post Coronary Artery Bypass Graft Surgery. Ann Pharmacother 2008; 42:421-4. [DOI: 10.1345/aph.1l009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Acute physiologic changes after bypass graft surgery may temporarily result in reduced drug elimination and dosing requirements for the desired effect. Substantially lower doses for drugs such as the direct thrombin inhibitor argatroban may need to be considered when initiating therapy soon after surgery if the therapeutic window is narrow and impaired liver, kidney, or cardiac function is present. Initial dosing approaches, with follow-up infusion rate adjustments and allowances for the extended time needed to establish and maintain an activated partial thromboplastin time value in the target ratio range, also need to consider the risk of thrombosis or bleeding complications. The duration of reduced dosing may depend on several variables, and, as systems recover, the dosage may need to be adjusted upwards. Retrospective analysis for identifying heparin-induced thrombocytopenia may be difficult in situations where other causes of thrombocytopenia are present, suggesting that posttest scoring methods also be considered to confirm its presence until better, validated methods become available.
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Affiliation(s)
- William E Dager
- University of California Davis Medical Center, Sacramento, CA; Clinical Professor of Pharmacy, School of Pharmacy, University of California at San Francisco, San Francisco, CA; Clinical Professor of Medicine, University of California Davis School of Medicine
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35
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Fugate S, Chiappe J. Standardizing the management of heparin-induced thrombocytopenia. Am J Health Syst Pharm 2008; 65:334-9. [DOI: 10.2146/ajhp070086] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Susan Fugate
- Department of Pharmacy, Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma, Oklahoma City
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Sterling J. Recent Publications on Medications and Pharmacy. Hosp Pharm 2007. [DOI: 10.1310/hpj4207-657] [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
Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics.
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