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Erich BJ, Knutson J, Barnes BJ. Analysis of heparin-induced thrombocytopenia diagnostic and management strategies in individuals with inconclusive antibody optical densities. Blood Coagul Fibrinolysis 2023; 34:272-280. [PMID: 37115961 DOI: 10.1097/mbc.0000000000001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is an uncommon but serious complication of exposure to heparin. Antibody optical densities (ODs) used to diagnose HIT exceeding 2 are highly suggestive of disease, whereas ODs less than 0.5 often 'rule out' HIT. Variation in the clinical care of patients with inconclusive ODs between 0.5 and 2 is likely. This single-centre, retrospective analysis evaluates the diagnosis, management and outcomes of those with antibody ODs between 0.5 and 2. We queried our institution's Healthcare Enterprise Repository for Ontological Narration (HERON) database to identify individuals with antibody ODs between 0.5 and 2. Chart review was completed to calculate 4T scores, corroborate diagnosis codes with documented information in our electronic health record (EHR) and evaluate the diagnosis, management and outcomes of these individuals. These data were evaluated using descriptive and univariate statistics. Among individuals evaluated for HIT between November 2007 and July 2020, we identified 302 individuals with ODs between 0.5 and 2. Serotonin release assays (SRAs) were assessed in 55% (165/302) and were positive in 12% (20/165). In those with available data, 96% with low 4T scores had negative SRAs and 4% had positive SRAs. As 4T scores and antibody ODs proportionally increased, SRA positivity also increased. Clinical management varied widely; however, 4T scoring remains a valuable assessment in this cohort. In those with HIT antibody ODs between 0.5 and 2, true positives were uncommon, and their clinical management varied widely. Fortunately, 4T scoring is a useful prognostic tool that improves the diagnosis and management among those with inconclusive HIT.
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Affiliation(s)
| | - Jace Knutson
- Inpatient Pharmacy, The University of Kansas Health System
| | - Brian J Barnes
- School of Pharmacy, The University of Kansas Medical Center, Kansas City, Kansas, USA
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Small BL, Gomes MP, McCurry KR, Han X, Ataya A, Akindipe O, Lane CR, Budev M. A Novel Diagnostic Algorithm for Heparin-Induced Thrombocytopenia in a Retrospective Cohort of Lung Transplant Recipients. Prog Transplant 2019; 30:4-12. [PMID: 31838929 DOI: 10.1177/1526924819892918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Heparin-induced thrombocytopenia (HIT) is characterized by thrombocytopenia and potential for thromboembolism. Lung transplant recipients are at risk of developing HIT due to heparin exposure peritransplant. We describe the incidence and impact of HIT in lung transplant recipient index hospital length of stay and survival. DESIGN A retrospective cohort was obtained from electronic medical records which were queried for all recipients treated with bivalirudin (institutional treatment of choice for HIT) between January 1, 2005, and February 16, 2017 (N = 1171). Patients who developed HIT >30 days after transplant or after their index transplant admission were excluded. A diagnostic algorithm was used retrospectively to determine clinical HIT with an intermediate or high pretest clinical suspicion ("4T" score ≥4) and either (1) positive anti-heparin-platelet-factor 4 (HPF4) assay and a positive functional platelet assay or (2) a positive HPF4 assay only, in patients who did not undergo cardiopulmonary bypass. RESULTS Among all lung transplant recipients, 2.1% were found to develop HIT in the peritransplant period (N = 25, mean = 88%) with a mean lung allocation score of 50.8 and an incidence of venous thromboembolism of 72%, most upper extremity in location. When matched with historical controls, patients with HIT had a longer overall index hospital length of stay of 43 days (P = .008). There was no difference in short- or long-term survival posttransplant. CONCLUSION Vigilance for the development of HIT in lung transplant recipients is necessary to prevent further morbidity from thromboembolic events. In our cohort, HIT increased hospital length of stay but did not appear to affect recipient survival.
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Affiliation(s)
- Bronwyn Larissa Small
- Pulmonary, Critical Care and Allergy Department, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marcelo P Gomes
- Department of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kenneth R McCurry
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaozhen Han
- Biostatistics Core, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Ataya
- Department of Pulmonary, Critical Care and Allergy, University of Florida, Gainesville, FL, USA
| | - Olufemi Akindipe
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - C Randall Lane
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marie Budev
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Poyant JO, Gleason AM. Early Identification of Argatroban Resistance and the Consideration of Factor VIII. J Pharm Pract 2019; 34:329-331. [PMID: 31694454 DOI: 10.1177/0897190019885232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Argatroban, a synthetic, parenteral, nonheparin anticoagulant, is a direct thrombin inhibitor indicated for the prophylaxis or treatment of venous thromboembolism (VTE) in patients with heparin-induced thrombocytopenia with thrombosis (HITT) and for use during percutaneous coronary intervention (PCI) in patients who have or are at risk for developing HITT. Although heparin resistance occurs in approximately 0.5% to 5% of heparin-treated patients and is well documented in the literature, argatroban resistance is limited to a single case report. The objective of this case is to describe a case in which argatroban resistance was suspected in a patient with critical limb ischemia. METHODS This is a case report of a single patient. RESULTS A 68-year-old female admitted for critical limb ischemia requiring vascular intervention was treated for presumed HITT with argatroban. A therapeutic activated partial thromboplastin time (aPTT) was not attained (31 seconds) despite multiple uptitrations of the dose to 2.8 μg/kg/min (adjusted based on the institutional protocol and with consideration of organ dysfunction). A coagulopathy workup revealed a high level of factor VIII (265%). CONCLUSION This case supports early assessment of factor VIII levels and the consideration of argatroban resistance and in patients who have a subtherapeutic aPTT, despite multiple increases in dose with an elevated factor VIII level. Early identification should prompt the use of an alternative anticoagulant to ensure efficacy.
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Affiliation(s)
- Janelle O Poyant
- Department of Pharmacy, 1867Tufts Medical Center, Boston, MA, USA
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Kabadi RA, Danelich IM, Entwistle JW, Marhefka GD, Reeves G, Boyle AJ, Qureshi AM. Use of Cangrelor as a Bridge to Left Ventricular Assist Device Implantation in a Patient with a Recent Drug-Eluting Stent Who Developed Acute Tirofiban-Related Thrombocytopenia. Pharmacotherapy 2019; 39:521-525. [PMID: 30644585 DOI: 10.1002/phar.2219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Current guidelines emphasize the need for at least 6-12 months of oral dual antiplatelet therapy consisting of aspirin and a P2Y12 inhibitor following drug-eluting coronary artery stent implantation. In patients with recently implanted coronary artery stents who require urgent cardiac or noncardiac surgery, the benefits of maintaining oral dual antiplatelet therapy must be carefully weighed against the risks of excessive bleeding, and current practice is largely guided by individual surgeon preferences. When the effects of a second oral antiplatelet agent are undesirable during the perioperative period, the use of a short-acting intravenous antiplatelet agent as "bridge" therapy that can be discontinued shortly before surgery is associated with a reduced occurrence of adverse clinical events in patients with recently implanted coronary stents requiring urgent coronary artery bypass graft surgery. Cangrelor is an intravenous adenosine triphosphate analog P2Y12 receptor antagonist with a short plasma half-life that has been used off label in patients with recent coronary stents as a bridge to invasive procedures with excessive bleeding risk. To our knowledge, this is the first case report to demonstrate the safe and effective use of cangrelor as a bridge to left ventricular assist device implantation in a patient with a recently implanted drug-eluting coronary artery stent who developed acute thrombocytopenia following reexposure to tirofiban, a glycoprotein IIb/IIIa inhibitor.
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Affiliation(s)
- Rajiv A Kabadi
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ilya M Danelich
- Department of Transplantation, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - John W Entwistle
- Department of Surgery, Division of Cardiothoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gregary D Marhefka
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gordon Reeves
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Andrew J Boyle
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ataul M Qureshi
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Gerstein W, Colombo E, Harji F. Documented vancomycin-induced severe immune-mediated thrombocytopaenia. BMJ Case Rep 2018; 2018:bcr-2018-224682. [PMID: 30150336 DOI: 10.1136/bcr-2018-224682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
A 69-year-old man developed Propionibacterium acnes left knee hardware infection after suffering from an infected ingrown toenail. The hardware was removed and he was treated with intravenous vancomycin. Ten days after initiation of vancomycin, he developed severe thrombocytopaenia, epistaxis and petechiae. Vancomycin was discontinued, and platelets rapidly recovered. Serum vancomycin IgG were positive. Patient completed a 6-week course of ceftriaxone with no further complications.
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Affiliation(s)
- Wendy Gerstein
- Department of Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA.,Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Elizabeth Colombo
- Department of Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA.,Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Farzana Harji
- Department of Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA.,Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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Haffner M, Heyrani N, Meehan JP, Giordani M. Enoxaparin-induced skin necrosis at injection site after total knee arthroplasty. Arthroplast Today 2018; 4:10-14. [PMID: 29560388 PMCID: PMC5859518 DOI: 10.1016/j.artd.2017.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 09/13/2017] [Accepted: 09/14/2017] [Indexed: 11/01/2022] Open
Abstract
Enoxaparin is a widely used low-molecular-weight heparin for perioperative thromboembolic prophylaxis. Enoxaparin-induced skin necrosis in the setting of arthroplasty has been rarely reported in the literature with varying outcomes and management decisions. Our patient developed skin necrosis at his injection site and thrombocytopenia 10 days following left total knee arthroplasty surgery and after receiving subcutaneous Lovenox injections postoperatively. The patient was started on an alternative anticoagulation based on a high suspicion for heparin-induced thrombocytopenia and the wound was monitored without surgical debridement. Our case highlights the key clinical management decisions when facing this potentially life-threatening adverse reaction.
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Affiliation(s)
- Max Haffner
- Department of Orthopaedics, University of California, Sacramento, CA, USA
| | - Nasser Heyrani
- Department of Orthopaedics, University of California, Sacramento, CA, USA
| | - John P Meehan
- Department of Orthopaedics, University of California, Sacramento, CA, USA
| | - Mauro Giordani
- Department of Orthopaedics, University of California, Sacramento, CA, USA
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Sheppard JA, Warkentin T, Shih A. Platelet count recovery and seroreversion in immune HIT despite continuation of heparin: further observations and literature review. Thromb Haemost 2017; 117:1868-1874. [DOI: 10.1160/th17-03-0212] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/16/2017] [Indexed: 11/05/2022]
Abstract
SummaryOne of the standard distinctions between type 1 (non-immune) and type 2 (immune-mediated) heparin-induced thrombocytopenia (HIT) is the transience of thrombocytopenia: type 1 HIT is viewed as early-onset and transient thrombocytopenia, with platelet count recovery despite continuing heparin administration. In contrast, type 2 HIT is viewed as later-onset (i. e., 5 days or later) thrombocytopenia in which it is generally believed that platelet count recovery will not occur unless heparin is discontinued. However, older reports of type 2 HIT sometimes did include the unexpected observation that platelet counts could recover despite continued heparin administration, although without information provided regarding changes in HIT antibody levels in association with platelet count recovery. In recent years, some reports of type 2 HIT have confirmed the observation that platelet count recovery can occur despite continuing heparin administration, with serological evidence of waning levels of HIT antibodies (“seroreversion”). We now report two additional patient cases of type 2 HIT with platelet count recovery despite ongoing therapeutic-dose (1 case) or prophylactic-dose (1 case) heparin administration, in which we demonstrate concomitant waning of HIT antibody levels. We further review the literature describing this phenomenon of HIT antibody seroreversion and platelet count recovery despite continuing heparin administration. Our observations add to the concept that HIT represents a remarkably transient immune response, including sometimes even when heparin is continued.
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Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated complication of heparin therapy. The use of heparin to flush some vascular access devices makes HIT a concern for infusion nurses. This article reviews the risk factors for, pathophysiology of, and management of HIT.
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Samuelson BT, Glynn E, Holmes M, White AA, Martin DB, Garcia D. Use of a computer-based provider order entry (CPOE) intervention to optimize laboratory testing in patients with suspected heparin-induced thrombocytopenia. Thromb Res 2015; 136:928-31. [DOI: 10.1016/j.thromres.2015.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/03/2015] [Accepted: 09/04/2015] [Indexed: 12/14/2022]
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Jourdy Y, Nougier C, Rugeri L, Bordet JC, Sobas F, Negrier C. Prospective evaluation of automatized PF4/heparin immunoassays HemosIL HIT-ab (PF4-H) for the diagnosis of heparin-induced thrombocytopenia. Int J Lab Hematol 2014; 37:244-52. [DOI: 10.1111/ijlh.12275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 06/16/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Y. Jourdy
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - C. Nougier
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - L. Rugeri
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - J. C. Bordet
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - F. Sobas
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
| | - C. Negrier
- Hemostasis Laboratory; Edouard Herriot Hospital; Lyon France
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Rowland SP, Rankin I, Sheth H. Vancomycin-induced thrombocytopaenia in a patient with severe pancreatitis. BMJ Case Rep 2013; 2013:bcr-2013-200830. [PMID: 24132444 DOI: 10.1136/bcr-2013-200830] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Vancomycin-induced thrombocytopenia is a rare side effect of a commonly used drug that may cause life-threatening disease. A 51-year-old man was treated for an episode of acute severe alcohol-induced pancreatitis complicated by development of a peripancreatic fluid collection. He developed fever of unknown origin and was treated with intravenous vancomycin and piperacillin with tazobactam. On day 6 of vancomycin therapy his platelet count dropped to 46×10(9)/L (237×10(9)/L on day 1 of treatment) and by day 8 of therapy platelets had fallen to a nadir of 9×10(9)/L. The patient at this stage displayed a florid purpuric rash and haematoma formation on attempted intravenous cannulation. A clinical diagnosis of vancomycin-induced thrombocytopaenia was made and the drug withdrawn. After 3 days a significant improvement in the platelet count was noted, rising to 56 × 10(9)/L. Immunofluorescence testing (PIFT) ruled out teicoplanin and heparin as causes of drug-induced thrombocytopenia.
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