Acute Severe Thrombocytopenia Occurring After Administration of Eptifibatide Postpones Emergent Coronary Artery Surgery

Introduction

Eptifibatide is a platelet glycoprotein IIb/IIIa (GP IIb/IIIa) receptor antagonist that inhibits fibrinogen binding to the activated GP IIb/IIIa site and prevents platelet-platelet interaction and clot formation. GP IIb/IIIa inhibitors improve outcome in patients undergoing percutaneous coronary intervention for acute coronary syndrome. Thrombocytopenia is a complication of GP IIb/IIIa inhibitors, but severe thrombocytopenia is unusual. Most reported cases of severe thrombocytopenia after eptifibatide occurred in patients with acute coronary syndrome. The authors describe a patient who developed acute profound thrombocytopenia after receiving eptifibatide before emergent coronary artery bypass graft surgery.

Case Presentation

A 67-year-old man with a normal platelet count (220 K/uL) developed atrial fibrillation, left bundle branch block, and respiratory insufficiency consistent with acute coronary syndrome two days after colectomy. He received eptifibatide during cardiac catheterization, where three-vessel coronary artery disease was encountered. Emergent coronary artery surgery was planned, but the platelet count before surgery was 2 K/uL. Eptifibatide was discontinued, surgery was postponed, and acute coronary syndrome was treated with intraaortic balloon counterpulsation.

Conclusions

The authors describe the second reported case of eptifibatide-induced severe thrombocytopenia associated with cardiac surgery. In this case, discontinuation of eptifibatide and transfusion of apheresis platelets increased the platelet count (137 K/uL) the following day, and the patient subsequently underwent successful coronary artery surgery using cardiopulmonary bypass.

Eptifibatide and Cirrhosis: Rethinking GPIIb-IIIa Inhibitors for Acute Coronary Syndrome in the Setting of Liver Dysfunction

Glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors, such as eptifibatide, are routinely used in the setting of acute coronary syndrome (ACS) prior to or during percutaneous coronary intervention (PCI). While numerous studies have demonstrated improved clinical outcomes with eptifibatide use, adverse effects including thrombocytopenia have also been noted. For this reason, patients with baseline thrombocytopenia or liver disease should be cautiously evaluated prior to drug administration. Here we report a case of acute profound and prolonged eptifibatide-induced thrombocytopenia in a patient with cirrhotic liver dysfunction. We propose and discuss the need for a risk stratification tool to be established for identifying which patients with ACS in the setting of chronic liver disease receive GPIIb/IIIa inhibitors.

Eptifibatide-Induced Thrombocytopenia--When Inhibitor Turns Killer

Eptifibatide is a commonly and widely used drug for management of acute coronary syndrome and during percutaneous coronary intervention. It is usually well tolerated with no major adverse effects. We report a rare case of life-threatening thrombocytopenia secondary to eptifibatide along with a literature review of available evidence.

Eptifibatide-Induced Thrombocytopenia and Subsequent Thrombosis

Objective:

To report a case of thrombocytopenia and thrombosis associated with the administration of eptifibatide.

Case Summary:

We describe the case of a 63-year-old male who developed thrombocytopenia and thrombosis associated with eptifibatide administration. Eptifibatide (2 μg/kg/min, following a 180-μg/kg bolus) was administered on hospital day 5, with a baseline platelet count of 302 × 103/μL. Ten hours after eptifibatide initiation in the catheterization laboratory, the patient experienced new-onset hypotension, shortness of breath, and tachycardia. Computed tomography angiography revealed bilateral, multilobar, pulmonary emboli. Platelet count decreased to 94 × 103/μL. Eptifibatide was discontinued and lepirudin 16.5 mg/h was administered because of high suspicion of heparin-induced thrombocytopenia (HIT). The platelet count returned to 127 × 103/μL on day 7. Heparin-induced platelet aggregation assay and antiplatelet factor 4 antibodies were negative. Eptifibatide-dependent platelet-reactive antibodies were detected in the patient's serum. The patient's platelet count continued to rise until day 16, when the patient was discharged on enoxaparin and warfarin.

Discussion:

Eptifibatide-associated thrombocytopenia has been described in several case reports, but concomitant thrombosis has been reported in only 2 cases. The Naranjo probability scale suggested a probable association between eptifibatide administration and the development of thrombosis and thrombocytopenia. Our patient also developed positive eptifibatide antibodies and had a negative HIT workup. These factors, in addition to the patient's clinical presentation, suggested that eptifibatide was the most likely cause of thrombocytopenia and thrombosis.

Conclusions:

Despite the low incidence of thrombocytopenia and subsequent thrombosis with eptifibatide administration, it is imperative that patients receiving this drug have careful monitoring of their platelet count. If patients develop a profound thrombocytopenia in the setting of eptifibatide administration, we recommend evaluation for venous thromboembolism until further information is available about this adverse drug reaction.

Eptifibatide induced profound thrombocytopenia in a patient with pelvic malignancy: A case report

► Eptifibatide is associated with profound thrombocytopenia and thrombosis secondary to a HITT-like mechanism associated with drug-dependant antibodies. ► Caution with eptifibatide use is needed in those pre-disposed to hypercoaguability, particularly those with an underlying malignancy.

Drug-induced thrombocytopenia in critically ill patients

Thrombocytopenia occurs in 15% to 58% of intensive care unit patients. The incidence varies based upon patient population, timing and frequency of platelet monitoring, and definition of thrombocytopenia. Up to 25% of acutely ill patients develop drug-induced thrombocytopenia. When drug-induced thrombocytopenia is suspected, nondrug related causes must be evaluated and excluded. Establishing the diagnosis of drug-induced thrombocytopenia is challenging, as hundreds of medications have been implicated. Medications commonly associated with drug-induced thrombocytopenia include glycoprotein IIb/IIIa inhibitors, cinchona alkaloids, antibiotics, anticonvulsants, and heparin. Once the diagnosis is suspected, clinicians should identify the start date of medications to assess the timeline of development. The likelihood of each medication causing thrombocytopenia must be evaluated. The risk vs. benefit of discontinuing the suspected medication and availability of alternative medications must be assessed. The role of corticosteroids, immune globulin, and plasmapheresis is uncertain. Once the offending agent has been discontinued, the overall prognosis is excellent. In the case of suspected or confirmed heparin-induced thrombocytopenia, an alternative anticoagulant should be initiated. Drug-induced thrombocytopenia should be documented in the medical record and reported according to institutional and national standards. This review focuses on immune-mediated drug-induced thrombocytopenia from medications commonly utilized in the critically ill patient.

Profound thrombocytopenia after primary exposure to eptifibatide

Eptifibatide is a glycoprotein IIb/IIIa receptor antagonist used to reduce the incidence of ischemic events in patients with acute coronary syndromes and those undergoing percutaneous coronary intervention. A minority of patients given eptifibatide develop acute, profound thrombocytopenia (<20,000 cells/mm(3)) within a few hours of receiving the drug. This case report discusses a patient who developed profound thrombocytopenia within hours of receiving eptifibatide for the first time. The Naranjo algorithm classified the likelihood that this patient's thrombocytopenia was related to eptifibatide as probable. Profound thrombocytopenia is an uncommon but clinically important complication of eptifibatide. This case report emphasizes the importance of monitoring platelet counts routinely at baseline and within 2-6 hours of eptifibatide administration.

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