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Heparin-Induced Thrombocytopenia Medication

  • Author: Sancar Eke, MD, FASN; Chief Editor: Srikanth Nagalla, MBBS, MS, FACP  more...
 
Updated: Oct 17, 2015
 

Medication Summary

The goals of pharmacotherapy in patients with heparin-induced thrombocytopenia (HIT) are to reduce morbidity and prevent complications. Anticoagulants used for prophylaxis and treatment of thrombosis in patients with HIT are the direct thrombin inhibitors (DTIs) argatroban (Acova) and bivalirudin. Bivalirudin is used in cardiac surgery and procedures in HIT patients[60, 62] .The indirect factor Xa inhibitor fondaparinux (Arixtra) is sometimes used off-label for HIT. After recovery of the platelet count, patients who require continuing anticoagulation can be transitioned to warfarin.

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Anticoagulants, Hematologic

Class Summary

Anticoagulants inhibit factors responsible for thromboembolic disorders. DTIs are the principal anticoagulants used for prophylaxis and treatment of thromboembolism in patients with HIT.

Argatroban (Acova)

 

Argatroban is a DTI; it inhibits fibrin formation, platelet aggregation, and activation of coagulation factors V, VIII, XIII, and protein C. The dose is 2 mcg/kg/min, adjusted by the activated partial thromboplastin time (aPTT) with a target of 1.5-3 times the baseline.

Argatroban is the ideal alternative to heparin for patients receiving dialysis, because it is not excreted by the kidneys and does not require dose adjustment in those patients.[51] However, because argatroban is processed by the liver, the initial dose should be reduced by 75% in patients with liver dysfunction.

Bivalirudin (Angiomax, Angiox)

 

Bivalirudin is a competitive, direct inhibitor of thrombin that inhibits both free and clot-bound thrombin and thrombin-induced platelet aggregation. This agent is approved for use in patients who are undergoing percutaneous coronary intervention (PCI) and have, or are at risk for, HIT or HIT with thrombosis (HITT).

Fondaparinux (Arixtra)

 

Fondaparinux is a synthetic anticoagulant that works by inhibiting factor Xa, a key component involved in blood clotting. It provides a highly predictable response. Bioavailability is 100%, has a rapid onset of action, and a half-life of 14-16 h, allowing for sustained antithrombotic activity over 24-h period. Fondaparinux does not affect prothrombin time or aPTT, nor does it affect platelet function or aggregation.

Warfarin (Coumadin, Jantoven)

 

Warfarin interferes with hepatic synthesis of vitamin K–dependent coagulation factors. It is used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders. To avoid warfarin-induced venous limb gangrene in patients with HIT and deep venous thrombosis, warfarin should not be started until the platelet count has risen above 150 x 109/L.[1, 49] Tailor the dose of warfarin to maintain an International Normalized Ratio (INR) in the range of 2 to 3.

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Contributor Information and Disclosures
Author

Sancar Eke, MD, FASN Physician in Nephrology and Hypertension, Washington

Sancar Eke, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology, American Society of Transplantation, American Society of Diagnostic and Interventional Nephrology

Disclosure: Nothing to disclose.

Coauthor(s)

Sarah K May, MD Consulting Staff, Department of Hematology-Oncology, Caritas Carney Hospital, Commonwealth Hematology-Oncology PC

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Srikanth Nagalla, MBBS, MS, FACP Director, Clinical Hematology, Cardeza Foundation for Hematologic Research; Assistant Professor of Medicine, Division of Hematology, Associate Program Director, Hematology/Medical Oncology Fellowship, Assistant Program Director, Internal Medicine Residency, Jefferson Medical College of Thomas Jefferson University

Srikanth Nagalla, MBBS, MS, FACP is a member of the following medical societies: American Society of Hematology, Association of Specialty Professors

Disclosure: Nothing to disclose.

Additional Contributors

Paul Schick, MD Emeritus Professor, Department of Internal Medicine, Jefferson Medical College of Thomas Jefferson University; Research Professor, Department of Internal Medicine, Drexel University College of Medicine; Adjunct Professor of Medicine, Lankenau Hospital

Paul Schick, MD is a member of the following medical societies: American College of Physicians, American Society of Hematology

Disclosure: Nothing to disclose.

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Ultrasonographic image of a deep vein thrombosis (DVT).
Sequential images demonstrate treatment of iliofemoral deep venous thrombosis due to May-Thurner (Cockett) syndrome. Far left: View of the entire pelvis demonstrates iliac occlusion. Middle left: After 12 hours of catheter-directed thrombolysis, an obstruction at the left common iliac vein is evident. Middle right: After 24 hours of thrombolysis, a bandlike obstruction is seen; this is the impression made by the overlying right common iliac artery. Far left: After stent placement, image shows wide patency and rapid flow through the previously obstructed region. Note that the patient is in the prone position in all views. (Right and left are reversed.)
Ventilation-perfusion scan. Left image: Posterior view of normal findings on ventilation-perfusion scan. Right image: Posterior view of a perfusion scan that reveals a perfusion defect in the left upper quadrant. The defect in the middle of the image is due to the position of the heart.
Helical computed tomography scan of the pulmonary arteries. A filling defect in the right pulmonary artery is present, consistent with a pulmonary embolism.
Table. 4Ts score [31, 34]
Feature Score
2 points 1 point 0 points
Thrombocytopenia >50% fall



and



platelet nadir 20-100 × 109/L



30%-50% fall



or



platelet nadir 10-19× 109/L



>30% fall



or



platelet nadir < 10× 109/L



Timing of platelet count fall Clear onset on day 5-10, or =1 d if heparin exposure within past 30 d Consistent with day 5-10 fall, but not clear (eg, missing platelet counts); onset after day 10; or fall = 1 day if heparin exposure 30-100 days ago Platelet count fall =4 d without recent heparin exposure
Thrombosis or other sequelae New thrombosis (confirmed); skin necrosis; acute systemic reaction after IV UHF bolus Progressive or recurrent thrombosis; erythematous skin lesions; thrombosis suspected but not proven None
Other causes of thrombocytopenia None apparent Possible Definite
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