Abciximab‐Associated Thrombocytopenia After Previous Tirofiban‐Related Thrombocytopenia

Abstract

A 62-year-old man with a history of coronary artery disease and coronary artery bypass graft, chronic heart failure, and peripheral vascular disease required percutaneous coronary intervention (PCI) after progression of shortness of breath and fatigue over 2 years. Four hours after the procedure, the patient developed hematemesis and was found to be thrombocytopenic. The thrombocytopenia was presumed to be due to the abciximab infusion the patient received during and shortly after the PCI. Further review of the patient's medical history revealed that a similar episode had occurred 11 years earlier. At that time, he was enrolled in a clinical trial comparing tirofiban and heparin in patients with unstable angina; he developed profound thrombocytopenia within 24 hours of randomization. After the study unblinding, investigators discovered that the patient received tirofiban, which was thought to be the cause of his thrombocytopenia. Both abciximab and tirofiban are glycoprotein IIb-IIIa inhibitors, and thrombocytopenia induced by this class of drugs is a serious and potentially life-threatening adverse reaction. The mechanism is not well understood but has been described as immune mediated with both ligand-mimetic agents (tirofiban and eptifibatide) and abciximab. Our patient's situation was unusual in that he developed thrombocytopenia from a ligand-mimetic agent and subsequently had a similar reaction to abciximab. To our knowledge, this case report is the first documentation of thrombocytopenia associated with both tirofiban and abciximab in a single patient, and suggests that care should be given in administering glycoprotein IIb-IIIa inhibitors of either type to patients with a history of thrombocytopenia due to one of these agents.

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

“…Acute thrombocytopenia related to GP IIb/IIIa inhibitor exposure was previously described and may occur in up to 4.2% of exposed patients receiving abiciximab and up to 1.9% receiving tirofiban . This adverse effect should prompt immediate discontinuation and contraindicate future exposure to this class of medications . Our patient's temporal relationship between tirofiban reexposure and his onset of thrombocytopenia in the absence of obvious alternative etiologies, as well as his subsequent platelet recovery following cessation of this agent, serve as compelling evidence that his thrombocytopenia was related to this drug.…”

A case of profound and prolonged tirofiban‐induced thrombocytopenia and its correction by intravenous immunoglobulin G

“…It is crucial for patient management to be able to switch to another GPIIb–IIIa inhibitor with lower or absent risk. Abciximab‐associated thrombocytopenia after previous tirofiban‐related thrombocytopenia has been reported but was not the case for our patient [12]. Our ELISA assay is a useful aid in diagnosis and in the selection of alternative therapy.…”

Thrombocytopenia after abciximab use results from different mechanisms

“…Our newly developed ELISA allows quick screening of samples and is much easier to perform than the two-step MAIPA. It also allows rapid assessment of the ability of abciximab-dependent antibodies to bind in the presence of other clinically used αIIbβ3 antagonists, tirofiban and eptifibatide, to help determine if they can be safely used to take up the relay in the event of new thrombotic episodes after the platelet count has recovered (17,46). Our study emphasises that abciximab-dependent antibodies do not constitute a major risk for most patients provided that their presence is acknowledged and that abciximab use is discontinued.…”