Dalteparin is safe to use if a person has a history of heparininduced thrombocytopenia. Heparin is one of the most frequently used anticoagulants. Coexistence of heparininduced thrombocytopenia and. A few invitro studies have shown that noacs do not interact with or release pf4 to cause activation or aggregation of platelets 11, thus making them a potentially good treatment option for hit. Heparin induced thrombocytopenia in a patient with factor. However, these patients are likely to require anticoagulation therapy at some point in the future. Clinical management of argatroban in patients with heparin. Target population adult patients with suspicion or diagnosis of heparin induced thrombocytopenia key practice recommendations screening for. Sunday, january 1, 2017 patients with a hematologic malignancy who are receiving curativeintent chemotherapy or hematopoietic cell transplantation hct have an increased risk of venous thromboembolism vte, despite commonly experiencing. Rivaroxaban is an ideal potential candidate for treatment of heparininduced thrombocytopenia hit because it is administered orally by fixed dosing, requires no laboratory monitoring and is effective in the treatment of venous and arterial thromboembolism in other settings. Also find the package insert, announcements, resources, and ways to connect with pfizer medical through a variety of channels. Use is contraindicated in patients with a history of heparininduced thrombocytopenia hit or hit with thrombosis. With the advent of improved and accessible diagnostic technology, for example, ultrasound andor spiral ct scans, timely diagnosis of venous thromboembolic events vte is readily accomplished. Vancomycininduced thrombocytopenia in a 60yearold man ncbi.
History of heparin induced thrombocytopenia or heparin induced thrombocytopenia with thrombosis. The pathogenic mechanisms of this condition are not fully understood. May 18 issue1 identified a difference in outcome favoring the use of lowmolecularweight heparin. Fragmin dalteparin sodium pfizer medical information. A 63yearold man with coronary artery disease who has recently undergone bypass surgery presents with dyspnea. Nonheparin anticoagulants for heparininduced thrombocytopenia. Evaluation of pretest clinical score 4 ts for the diagnosis of heparininduced thrombocytopenia in two clinical settings.
Venous limb gangrene has been reported to occur after high warfarin doses in heparininduced thrombocytopenia hit, and this observation has been used to exclude warfarin management in this condition. Although ototoxicity and nephrotoxicity are well known side effects of vancomycin, it can also induce platelet reactive antibodies leading to life. The primary objective of this study was to evaluate the impact of collaboration between an inpatient pharmacydriven anticoagulation management service ams and hospital reference laboratory to reduce inappropriate hit antibody. Laboratory testing reveals a platelet count of 86,000 per cubic millimeter, as compar. One of these is heparininduced thrombocytopenia syndrome hits, which develops in about 35% of patients exposed to heparin and is associated with thrombosis in 1% of cases. Request pdf argatroban anticoagulation for heparin induced thrombocytopenia in patients with ventricular assist devices patients receiving implantation of ventricular assist devices vad. Safety of warfarin anticoagulation in patients with. Evidencebased guidelines for managing patients with immune thrombocytopenia itp were last presented by. Clinical use of the lowmolecularweight heparins in. Dalteparin is treatment of choice for cancer patients with vte.
The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Managing immune thrombocytopenia nejm journal watch. Antithrombotic therapy is required to manage heparin induced thrombocytopenia hitbut currently approved agents such as argatroban must be given parenterally and closely monitored. Edoxaban noninferior to dalteparin for cancerassociated vte. Intravenous heparin and oral warfarin were initiated for anticoagulation. Eleven days after starting heparin therapy, the platelet count suddenly decreased to below 50,000. Vte prevention guidelines version 2 page 1 of 22 july 2012. Several agents are in clinical use for this condition, including parenteral. Fragmin medication page for healthcare professionals to search for scientific information on pfizer medications. The management of patients with heparininduced thrombocytopenia who require anticoagulant therapy kathryn hassell, md for patients with heparininduced thrombocytopenia hit, reexposure to heparin is generally not recommended. Heparininduced thrombocytopenia hit is a prothrombotic disorder with autoimmunelike features.
Heparininduced thrombocytopenia is the development of thrombocytopenia due to the administration of heparin. Riia on the platelet surface, platelets become activated, microparticles are released, and the coagulation cascade is triggered. Warfarininduced venous limb gangrene following heparin. The dif ferential diagnosis of thrombocytopenia and the potential secondary causes of itp are outlined. Heparininduced thrombocytopenia uicadvocate christ internal. The introduction of lowmolecularweight heparin lmwh approximately two decades ago in. Can patients with thrombocytopenia undergoing chemotherapy or transplant safely receive anticoagulation. The oral anticoagulant edoxaban appears noninferior to subcutaneous dalteparin for managing venous thromboembolism vte in adults with cancer, according to an industrysupported, noninferiority trial published in the new england journal of medicine and presented at the american society of hematologys annual meeting.
Heparininduced thrombocytopenia associated with pulmonary. Heparininduced thrombocytopenia hit is an immunemediated hypercoagulable disorder caused by antibodies to platelet factor 4 pf4 and heparin. Heparininduced thrombocytopenia and optimal management of. The following guideline is intended to guide the management of heparin induced thrombocytopenia and includes recommendations for diagnosis and treatment agents. Dalteparin prescribing information for primary care indication dose of dalteparin duration of treatment prophylaxis of vte nice ng89 5000 units once daily 2500 units daily in dialysis patients. Background heparin induced thrombocytopenia is a relatively common antibodymediated drug reaction. Twelve days after starting heparin, an aboveknee amputation was required for. Heparininduced thrombocytopenia hit is a serious, acquired, prothrombotic disorder caused by an antibody response to the heparinplatelet factor 4 complex, which can precipitate arterial as well as venous thromboembolic complications.
Type ii heparininduced thrombocytopenia hit is a lifethreatening adverse drug reaction initiated by heparin administration. Hit is caused by antibodies that recognize complexes of platelet factor 4 and heparin. Heparininduced thrombocytopenia is a clinicopathologic syndrome that can be associated with severe complications and significant mortality. We studied the temporal relation between previous or current heparin therapy and the onset of hep. Key clinical pointsheparin induced thrombocytopenia heparin induced thrombocytopenia hit is characterized by a decrease in the platelet count of more than 50% from the highest platelet count valu.
N engl j med dec at 23 years of followup, life expectancy was nearly 3 years longer with prostatectomy than with watchful waiting. Successful use of alternative anticoagulants in the. Thrombotic thrombocytopenic purpura ou health sciences center. Clinical picture of heparininduced thrombocytopenia hit and its differentiation from nonhit thrombocytopenia. Heparininduced thrombocytopenia develops in a 57yearold man who underwent kneereplacement surgery 7 days previously. C dalteparin is administered by intramuscular injection.
Correspondence from the new england journal of medicine heparin induced thrombocytopenia nejm. Argatroban anticoagulation in patients with heparin. Fragmin dalteparin sodium injection for subcutaneous. Heparin induced thrombocytopenia hit is characterized by a decrease in the platelet count of more than 50% from the highest platelet count value after the start of heparin, an onset 5 to 10 days. The propensity for thrombosis distinguishes hit from other common druginduced. Clinical practice guideline august 20 general principles. Chong and others published failure of orgaran therapy in a patient with a previous heparin. The approval was based on data from the clot randomized comparison of low.
Background heparininduced thrombocytopenia hit is an intensely prothrombotic syndrome managed by discontinuation of heparin therapy and substitution of an alternative inhibitor of thrombin. Temporal aspects of heparininduced thrombocytopenia nejm. Misdiagnosis of heparininduced thrombocytopenia hit is common and exposes patients to highrisk therapies and potentially serious adverse events. The use of heparin to flush some vascular access devices makes hit a concern for infusion nurses. It is a main objective of this registry to mirror the. The new england journal of medicine downloaded from nejm. Up to 50% of patients undergoing coronary artery bypass surgery will develop antibodies against the heparinplatelet factor 4 complex, and a small percentage of those will go on to develop heparin. Lo gk, juhl d, warkentin te, sigouin cs, eichler p, greinacher a. Retrospective registry of patients with acute heparin. Heparin induced thrombocytopenia adult inpatient clinical. Heparin induced thrombocytopenia hit is an adverse drug reaction characterized by thrombocytopenia and a high risk for venous or arterial thrombosis. Learn vocabulary, terms, and more with flashcards, games, and other study tools.
In conjunction with this change, new guidelines for management of suspected hit. Complications of hit are venousarterial thrombosis, skin gangrene, and acute platelet activation syndrome. The purpose of this retrospective registry is to collect data about patients with acute hit ii heparininduced thrombocytopenia type ii which were treated with lepirudin, danaparoid, argatroban or fondaparinux. We described a rare case of lmwhinduced hit complicated with proven pulmonary embolism pe in a 75yearold male patient who hospitalized with diagnose of right knee osteoarthritis and was underwent total knee arthroplasty. Lmwhs are not fully reversible with protamine because of the differing chain lengths of the lmwh molecule. B dalteparin is safe to use in a patient receiving concurrent neuraxial anesthesia. Hemonc today the fda has approved dalteparin for extended treatment of venous thromboembolism for patients with cancer. A brief overview of the pathophysiology, diagnosis, and treatment of heparininduced thrombocytopenia hit is discussed. The identification and management of heparininduced. New guidelines for heparininduced thrombocytopenia. Correspondence from the new england journal of medicine heparin induced thrombocytopenia. Hit should be suspected in patients exposed to heparin who present with an unexplained thrombosis or a significant drop in platelet count, or both. Interrupt or discontinue therapy in patients with platelet counts pdf. Patients with malignant neoplastic diseases represent a highrisk population relative to thromboembolic disease.
On september 3, 20 uwmedicine laboratory services released a new reflexive panel for hit antibody testing. Current guidelines recommend cessation of heparin for patients strongly suspected of having hit and prompt initiation of a nonheparin direct thrombin inhibitor for anticoagulation, such as argatroban or bivalirudin. Hit develops in temporal association with heparin therapy and manifests either as an unexplained thrombocytopenia or thrombocytopenia complicated by thrombosis. Patients with a history of antibody induced thrombocytopenia on ufh should not be treated with lmwh. Orlando, florida cancer patients often need therapeutic anticoagulation for venous thromboembolism vte, but they often have coexisting chemotherapyinduced thrombocytopenia cit. Lmwhs include enoxaparin, nadroparin, tinzaparin, and dalteparin. Platelet activation in heparininduced thrombocytopenia is. Heparininduced thrombocytopenia hit is an immunemediated complication of heparin therapy. Heparininduced thrombocytopenia hit is a lifethreatening complication of exposure to heparin ie, unfractionated heparin, low molecular weight lmw heparin that occurs in up to 5 percent of patients exposed, regardless of the dose, schedule, or route of administration.
Anticoagulation in cancer patients with thrombocytopenia. It is easy to use, but can be associated with lifethreatening side effects. The pathophysiology of heparininduced thrombocytopenia includes an immunemediated reaction to heparin that activates platelets and results in an acquired hypercoagulability. Extensive life threatening thrombosis in a patient with heparin induced thrombocytopenia and the factor v.
The immune response targets the self protein, platelet factor 4 pf4, which forms autoreactive epitopes when it binds to pharmacologic heparin or certain other polyanions, including plateletassociated chondroitin sulfate. Can patients with thrombocytopenia undergoing chemotherapy. Patients receiving implantation of ventricular assist devices vad suffer a high incidence of heparin induced thrombocytopenia hit. The outcome of patients receiving modest doses of warfarin was studied. Clinical management of argatroban in patients with heparin induced thrombocytopenia type ii. Fragmin dalteparin dosing, indications, interactions.
The last three have been compared with placebo, ufh, or enoxaparin. Listing a study does not mean it has been evaluated by the u. The rivaroxaban for hit study is a prospective, multicentre, singlearm, cohort study evaluating the. We describe our experience with argatroban, a direct thrombin inhibitor, in. History of heparin induced thrombocytopenia or heparin induced thrombocytopenia with thrombosis 4 hypersensitivity to dalteparin sodium 4, 6. Heparininduced thrombocytopenia shaikh n j emerg trauma shock.
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