INR matters: A case on managing argatroban for bridging oral anticoagulation in a patient with heparin induced thrombocytopenia type II after mechanical heart valve replacement

Raaz, Uwe; Maegdefessel, Lars; Buerke, Michael; Janusch, Matthias; Werdan, Karl; Schlitt, Axel

doi:10.1016/j.thromres.2008.08.023

Cited by 6 publications

(5 citation statements)

References 3 publications

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“…An alternative to selecting fondaparinux as the parenteral bridging agent would have been selection of a direct thrombin inhibitor (DTI). There have been some published case reports on the use of DTIs in patients with mechanical heart valves whose medical course was complicated by HIT [11,12]. Yet, the literature supporting DTI use in such patients is quite limited.…”

Section: Discussionmentioning

confidence: 99%

Successful use of fondaparinux in a patient with a mechanical heart valve replacement and a history of heparin-induced thrombocytopenia

Corbett

Elher

Garwood

2010

J Thromb Thrombolysis

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The development of heparin-induced thrombocytopenia (HIT) is an antibody-mediated clinicopathologic syndrome. The resultant thrombocytopenia and thrombosis can be severe and life-threatening. Fondaparinux is a parenteral factor Xa inhibitor used for venous thromboembolism prevention and treatment. Fondaparinux has minimal affinity for platelet factor 4, making it an alternative agent to unfractionated heparin (UFH) and low-molecular weight heparin (LMWH) and a plausible consideration for patients with a history of HIT. The use of fondaparinux in patients with mechanical heart valve replacement and a history of HIT has never been discussed in the literature. We report on the case of a patient with a mechanical aortic heart valve replacement and a history of HIT who was successfully bridged postoperatively with fondaparinux. While there is currently no literature to support the use of fondaparinux in patients with mechanical heart valves, this drug may offer an option for management of such patients who cannot use heparin products. However, further clinical investigations are warranted to confirm both the safety and efficacy of this agent in the mechanical heart valve population.

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Section: Discussionmentioning

confidence: 99%

Successful use of fondaparinux in a patient with a mechanical heart valve replacement and a history of heparin-induced thrombocytopenia

Corbett

Elher

Garwood

2010

J Thromb Thrombolysis

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“…1,2 While intravenous DTIs such as bivalirudin and argatroban possess these advantages over heparin, their use as a bridge to warfarin is often complicated by a false prolongation of the prothrombin time (PT) and international normalized ratio (INR). 1,[3][4][5][6] The prolongation in PT/INR is likely a result of the interaction between DTIs and the thromboplastin and tissue factor contained in the PT assay, along with the high molar concentrations of the DTIs needed to achieve their anticoagulant effect. 7 As a result, the INR while on a DTI may not represent the patient's true degree of anticoagulation.…”

Section: Introductionmentioning

confidence: 99%

Development of a Predictive Nomogram for the Change in PT/INR Upon Discontinuation of Bivalirudin as a Bridge to Warfarin

Hohlfelder

Deicicchi

Sylvester

et al. 2016

Clin Appl Thromb Hemost

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Appropriate timing of bivalirudin discontinuation as a bridge to warfarin is complicated, as bivalirudin may cause a falsely prolonged international normalized ratio (INR). The purpose was to evaluate patient and medication characteristics associated with differences in INR prolongation caused by bivalirudin. Adult patients receiving bivalirudin as a bridge to warfarin in 2014 were retrospectively evaluated. Patients were excluded if they had known thrombophilia or inappropriate INR monitoring after discontinuation of bivalirudin. Data recorded included indication for bivalirudin use, bivalirudin dosing, and coagulation assays. Univariate analysis was performed to determine variables associated with a larger change in INR when discontinuing bivalirudin. Variables with P < .3 were included in multivariate analysis. In total, 50 patient admissions were included in the analysis. Patients with ventricular assist devices represented the majority of the patient population (74%). The most common INR goals were 2.0 to 3.0 and 2.5 to 3.5. The mean initial weight-based bivalirudin rate was 0.076 mg/kg/h, and the mean increase in INR when starting bivalirudin was 0.6. The mean final weight-based bivalirudin rate was 0.13 mg/kg/h, and the mean change in INR after stopping bivalirudin was 0.8. On multivariate analysis, factors associated with a larger change in INR after stopping bivalirudin included higher serum creatinine ( P = .033), greater change in INR after initiation of bivalirudin ( P = .028), and higher final bivalirudin rate ( P < .001). The change in INR when starting or stopping bivalirudin appears to be patient specific and dose related. A nomogram was developed to predict the ideal timing of bivalirudin discontinuation. Prospective evaluation of the nomogram is under way.

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“…The efficacy of anticoagulation in patients who have had HIT must be checked frequently by an experienced team; the efficacy of argatroban is guided by aPTT values. Intravenously administered argatroban raises the INR by about one point, making the later reinstatement of VKA treatment more difficult (11,12).…”

Section: Unfractionated Heparinmentioning

confidence: 99%

“…The simultaneous intake of ASA and a P2Y 12 inhibitor-usually by patients who have received a coronary stent-can cause major problems in the perioperative period (Figure 2).…”

Section: Management Of Dual Inhibition Of Platelet Aggregationmentioning

confidence: 99%

“…According to the current recommendations, patients with a coronary stent must take ASA for life and a P2Y 12 inhibitor either for at least six weeks (bare metal stents [BMS]) or for at least twelve months (drug eluting stents [DES]) (31). Dual inhibition of platelet aggregation is also recommended for twelve months in patients who have had an acute coronary syndrome.…”

Section: Management Of Dual Inhibition Of Platelet Aggregationmentioning

confidence: 99%

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The Perioperative Management of Treatment With Anticoagulants and Platelet Aggregation Inhibitors

Schlitt

Jámbor²,

Spannagl³

et al. 2013

Deutsches Ärzteblatt International

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SUMMARYBackground: When giving anticoagulants and inhibitors of platelet aggregation either prophylactically or therapeutically, physicians face the challenge of protecting patients from thromboembolic events without inducing harmful bleeding. Especially in the perioperative period, the use of these drugs requires a carefully balanced evaluation of their risks and benefits. Moreover, the choice of drug is difficult, because many different substances have been approved for clinical use. Method: We selectively searched for relevant publications that appeared from

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INR matters: A case on managing argatroban for bridging oral anticoagulation in a patient with heparin induced thrombocytopenia type II after mechanical heart valve replacement

Cited by 6 publications

References 3 publications

Successful use of fondaparinux in a patient with a mechanical heart valve replacement and a history of heparin-induced thrombocytopenia

Successful use of fondaparinux in a patient with a mechanical heart valve replacement and a history of heparin-induced thrombocytopenia

Development of a Predictive Nomogram for the Change in PT/INR Upon Discontinuation of Bivalirudin as a Bridge to Warfarin

The Perioperative Management of Treatment With Anticoagulants and Platelet Aggregation Inhibitors

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