Heparin-Induced Thrombocytopenia Medication

Updated: Dec 12, 2019
  • Author: Sancar Eke, MD, FASN; Chief Editor: Srikanth Nagalla, MBBS, MS, FACP  more...
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Medication

Medication Summary

Treatment of heparin-induced thrombocytopenia involves discontinuing heparin and starting a non-heparin anticoagulant. American Society of Hematology guidelines suggest that some agents may be preferred in certain circumstances, as follows [54] :

  • Patients with critical illness, increased bleeding risk, or increased potential need for an urgent procedure - Argatroban or bivalirudin (because of their shorter duration of effect)
  • Clinically stable patients - Fondaparinux or a direct oral anticoagulant (DOAC) (because of their ease of administration, lack of need for lab monitoring, and feasibility of outpatient use) 
  • Life-threatening or limb-threatening thrombosis - Argatroban, bivalirudin, danaparoid, or fondaparinux
  • Moderate or severe hepatic dysfunction (Child-Pugh Class B and C) - Avoid argatroban or use a reduced dose; avoid DOACs

The choice of non-heparin anticoagulant may also be influenced by drug factors (eg, availability, cost, route of administration), patient factors (eg, kidney function, liver function), and clinician experience. [44, 54]  For example, in patients with HIT who have thrombosis and renal insufficiency, American College of Chest Physicians (ACCP) guidelines suggest using argatroban; in those with normal renal function, the ACCP suggests using argatroban, lepirudin, or danaparoid. [44]

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Anticoagulants, Hematologic

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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