Comparison of Bivalirudin and Argatroban for the Management of Heparin‐Induced Thrombocytopenia

Skrupky, Lee P.; Smith, Jennifer; Deal, Eli N.; Arnold, Heather; Hollands, James M.; Martinez, Emily; Micek, Scott T.

doi:10.1592/phco.30.12.1229

Cited by 55 publications

(71 citation statements)

References 22 publications

(48 reference statements)

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“…Overall, the probability of HIT being the explanation for thrombocytopenia in the ICU is only approximately 1 in 100. 13 However, some studies of DTI therapy for suspected HIT indicate that the majority (75%-80%) of those treated were ICU patients, 14,15 inferring overdiagnosis.…”

Section: Assessment Of Pretest Probabilitymentioning

confidence: 99%

How I Diagnose and Manage HIT

2011

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Heparin-induced thrombocytopenia (HIT) is a prothrombotic drug reaction caused by platelet-activating IgG antibodies that recognize platelet factor 4 (PF4)/polyanion complexes. Platelet activation assays, such as the serotonin-release assay, are superior to PF4-dependent immunoassays in discerning which heparin-induced antibodies are clinically relevant. When HIT is strongly suspected, standard practice includes substituting heparin with an alternative anticoagulant; the 2 US-approved agents are the direct thrombin inhibitors (DTIs) lepirudin and argatroban, which are "niche" agents used only to manage HIT. However, only ϳ 10% of patients who undergo serological investigation for HIT actually have this diagnosis. Indeed, depending on the clinical setting, only 10%-50% of patients with positive PF4-dependent immunoassays have platelet-activating antibodies. Therefore, overdiagnosis of HIT can be minimized by insisting that a positive platelet activation assay be required for definitive diagnosis of HIT. For these reasons, a management strategy that considers the real possibility of non-HIT thrombocytopenia is warranted. One approach that I suggest is to administer an indirect, antithrombin (AT)-dependent factor Xa inhibitor (danaparoid or fondaparinux) based upon the following rationale: (1) effectiveness in treating and preventing HIT-associated thrombosis; (2) effectiveness in treating and preventing thrombosis in diverse non-HIT situations; (3) both prophylactic-and therapeutic-dose protocols exist, permitting dosing appropriate for the clinical situation; (4) body weight-adjusted dosing protocols and availability of specific anti-factor Xa monitoring reduce risk of under-or overdosing (as can occur with partial thromboplastin time [PTT]-adjusted DTI therapy); (5) their long half-lives reduce risk of rebound hypercoagulability; (6) easy coumarin overlap; and (7) relatively low cost.

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Section: Assessment Of Pretest Probabilitymentioning

confidence: 99%

How I Diagnose and Manage HIT

2011

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“…Based on these pharmacokinetic properties, bivalirudin has become an attractive treatment option for HIT. [25][26][27][28][29][30][31][32] Problem DTI dosage adjustment can be problematic, as underdosing can increase the risk of thrombosis and overdosing may increase the risk of bleeding. The use of dosing nomograms has been shown to improve the safety, efficacy, and efficiency of anticoagulant therapy.…”

mentioning

confidence: 99%

“…[33][34][35][36][37][38] Given the favorable pharmacokinetic properties of bivalirudin, standardized dosing adjustments similar to those used to guide heparin administration could be considered. Bivalirudin has been shown to have a safety and efficacy profile similar to that of other DTIs, 14,30 but to our knowledge, the professional literature does not contain any published studies focused on the development or evaluation of a standardized, nurse-driven, slidingscale nomogram to facilitate ease of administration and patient safety.…”

mentioning

confidence: 99%

Development and implementation of a nurse-driven, sliding-scale nomogram for bivalirudin in the management of heparin-induced thrombocytopenia

Burcham

Abel

Gerlach

et al. 2013

American Journal of Health-System Pharmacy

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“…Since aPTT has been proved to be a good marker for monitoring ARG anticoagulation [20], we investigated its influence on the coagulation system by assessing aPTT. As shown by the AUC values of aPTT, there was no significant difference between the two groups, which proved that similarly to heparin-free dialysis, HD with the ARG dialyzer had little influence on the whole coagulation system.…”

Section: Discussionmentioning

confidence: 99%

Hemodialysis with a Dialyzer Loaded with Argatroban May Be Performed in vivo without a Systemic Anticoagulant

et al. 2012

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Background/Aims: Anticoagulation in hemodialysis (HD) patients at high risk of bleeding remains an intractable problem. Simulating endothelial cells by releasing anticoagulant on the membrane may be a promising alternative. Methods: We modified a polyacrylonitrile (PAN) dialyzer by loading argatroban into its membrane and verified its anticoagulation efficiency and its influence on coagulation markers such as activated partial thromboplastin time (aPTT), D-dimer and thrombin-antithrombin complex (TAT) in an animal HD model. Results: All HD sessions with the argatroban dialyzer were completed successfully with either no or minimal fiber clotting. D-dimer was lower in the argatroban group than in the PAN group; TAT and aPTT values were similar in the two groups, which suggests better anticoagulation and a similar influence on the coagulation system. Conclusion: HD with the argatroban dialyzer is feasible, safe and simple, and could be used in patients at high risk of bleeding.

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Comparison of Bivalirudin and Argatroban for the Management of Heparin‐Induced Thrombocytopenia

Abstract: Bivalirudin and argatroban were similar in achieving and maintaining therapeutic anticoagulation goals, clinical outcomes, and safety. This study suggests that bivalirudin represents an alternative in the management of HIT, but prospective studies are needed.

Cited by 55 publications

References 22 publications

How I Diagnose and Manage HIT

How I Diagnose and Manage HIT

Development and implementation of a nurse-driven, sliding-scale nomogram for bivalirudin in the management of heparin-induced thrombocytopenia

Hemodialysis with a Dialyzer Loaded with Argatroban May Be Performed in vivo without a Systemic Anticoagulant

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