The Incidence of Recognized Heparin-Induced Thrombocytopenia in a Large, Tertiary Care Teaching Hospital

Smythe, Maureen A.; Koerber, John M.; Mattson, Joan C.

doi:10.1378/chest.06-2109

Cited by 156 publications

(90 citation statements)

References 11 publications

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“…3,4 HIT is a profound hypercoagulability state 5 strongly associated with thrombosis. 6,7 Moreover, HIT is relatively common: although it occurs in only ;0.2% of hospitalized patients undergoing any heparin exposure, 8 it is more common in certain high-risk patient populations. For example, the frequency of HIT is ;5% in postorthopedic surgery patients receiving unfractionated heparin (UFH) for 10 to 14 days.…”

Section: Introductionmentioning

confidence: 99%

How I treat patients with a history of heparin-induced thrombocytopenia

Warkentin

Anderson

2016

Blood

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Heparin-induced thrombocytopenia (HIT) is a relatively common prothrombotic adverse drug reaction of unusual pathogenesis that features platelet-activating immunoglobulin G antibodies. The HIT immune response is remarkably transient, with heparin-dependent antibodies no longer detectable 40 to 100 days (median) after an episode of HIT, depending on the assay performed. Moreover, the minimum interval from an immunizing heparin exposure to the development of HIT is 5 days irrespective of the patient’s previous heparin exposure status or history of HIT. This means that short-term heparin reexposure can be safely performed if platelet-activating antibodies are no longer detectable at reexposure baseline and is recommended when heparin is the clear anticoagulant of choice, such as for cardiac or vascular surgery. The risk of recurrent HIT 1 to 2 weeks after heparin reexposure is ∼2% to 5% and is attributable to formation of delayed-onset (or autoimmune-like) HIT antibodies that activate platelets even in the absence of pharmacologic heparin. Some studies suggest that longer-term heparin reexposure (eg, for chronic hemodialysis) may also be reasonable. However, for other antithrombotic indications that involve patients with a history of HIT (eg, treatment of venous thromboembolism or acute coronary syndrome), preference should be given to non-heparin agents such as fondaparinux, danaparoid, argatroban, bivalirudin, or one of the new direct-acting oral anticoagulants as appropriate.

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Section: Introductionmentioning

confidence: 99%

How I treat patients with a history of heparin-induced thrombocytopenia

Warkentin

Anderson

2016

Blood

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“…Finally, we limited our scope on those costs related to HITs actually occurring and preventable with dabigatran, whereas also just suspected HITs already generate costs. Additionally, averted HIT in general not only provides cost savings, but also reduces (though relatively rare) devastating complications 37 . For the specific Dutch setting, our cost-minimization approach was relevant and appropriate.…”

Section: Discussionmentioning

confidence: 99%

Economic evaluation of dabigatran etexilate for the primary prevention of venous tromboembolic events following major orthopedic surgery in the Netherlands

Postma

Kappelhoff

Hulst

et al. 2012

Journal of Medical Economics

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c i a l D i s t r i b u t i o n U n a u t h o r i z e d u s e p r o h i b i t e d . A u t h o r i s e d u s e r s c a n d o w n l o a d , d i s p l a y , v i e w a n d p r i n t a s i n g l e c o p y f o r p e r s o n a l u s eJournal of Medical Economics Vol. 15, No. 5, 2012, 878-886 Dabigatran etexilate is a new oral direct thrombin inhibitor for prophylaxis of venous thromboembolism (VTE) in patients who have elective surgery for total hip replacement (THR) or total knee replacement (TKR). Among the advantages of dabigatran etexilate over subcutaneous prophylaxis with Low Molecular Weight Heparin (LMWH) are reduced resource uses for (i) teaching patients to self-inject; (ii) home-care visits for subcutaneous administration; and (iii) absence of heparin-induced thrombocytopenia (HIT). Based on the demonstrated non-inferiority, the aim of this study was to conduct a cost-minimization analysis of oral dabigatran etexilate vs subcutaneous low-molecular weight heparin (LMWH) and fondaparinux from the Dutch healthcare perspective. Methods:A retrospective cohort study was conducted to measure resource use associated with subcutaneous prophylaxis. Results of this study were used in the model to elucidate specific advantages of dabigatran etexilate, next to reduced needs for self-inject teaching and lack of Heparin-Induced Thrombocytopenia. Drug and other resource utilization data were combined with local unit costs. Probabilistic sensitivity analysis was performed to account for uncertainty around relevant parameters included. Results:Home-care visits for subcutaneous administration problems were needed in 9.9% (95% CI ¼ 6.4-13.4) and 9.6% (95% CI ¼ 5.8-13.4) of THR and TKR patients, respectively. Based on costs for 1000 patients treated with dabigatran etexilate vs LMWHs, per patient cost-savings with dabigatran etexilate were estimated at E30.68 (95% CI ¼ 2.01-65.52) and E23.19 (95% CI ¼ 0.69-48.48) for THR and TKR, respectively. The probability that dabigatran etexilate would be cost-saving was estimated at 98.3% and 97.9% for THR and TKR, respectively. These cost-savings were even higher when including fondaparinux in the analysis, with per patient cost-savings of E69.87 (43.42-106.10) and E18.33 (1.63-41.26) for THR and TKR, respectively. Separate calculations for dabigatran etexilate vs nadroparin and dalteparin in THR resulted in probabilities of achieving cost-savings with dabigatran etexilate of 36.2% and 100%, respectively. For TKR these probabilities were estimated at 54.3% and 100%, respectively. Conclusions:Thromboprophylaxis with dabigatran etexilate is cost-saving in patients undergoing THR and TKR from the Dutch healthcare perspective, compared to subcutaneous LMWHs.878 Economic evaluation of dabigatran etexilate Postma et al.

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“…Because of variations in the incidence of HIT reported in different studies, we performed an additional sensitivity analysis incorporating a lower incidence of HIT, specifically the 0.2% rate reported by Smythe et al in 24 068 patients admitted to a large teaching hospital. 47 The model structure and assumptions otherwise remained the same as in the primary analysis.…”

Section: Additional Sensitivity Analysesmentioning

confidence: 99%

Cost-effectiveness of anticoagulants for suspected heparin-induced thrombocytopenia in the United States

Aljabri

Huckleberry

Karnes

et al. 2016

Blood

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• Fondaparinux was the most cost-effective agent for suspected HIT, prevailing over both argatroban and bivalirudin.• Our data suggest potential cost savings with fondaparinux and underscore the need for larger clinical studies of fondaparinux in this area.Despite the availability of multiple nonheparin anticoagulants for the treatment of heparin-induced thrombocytopenia (HIT), few data are available comparing the costeffectiveness of these agents. This analysis is particularly important when considering differences in the risk of adverse effects, routes of administration, requirements for phlebotomy and laboratory monitoring, and overall drug costs. We conducted a costeffectiveness analysis of argatroban, bivalirudin, and fondaparinux for the treatment of suspected HIT from the institutional perspective. A 3-arm decision-tree model was developed that employs standard practices for anticoagulation monitoring. We incorporated published data on drug efficacy and probability of HIT-related thromboembolism and major bleeding. We considered both institutional costs and average wholesale price (AWP) and performed probabilistic sensitivity analyses (PSA) to address any uncertainty in model parameters. Using institutional costs, fondaparinux prevailed over both argatroban and bivalirudin in terms of cost ($151 vs $1250 and $1466, respectively) and adverse events averted (0.9989 vs 0.9957 and 0.9947, respectively). Results were consistent when AWP was used, with fondaparinux being less expensive ($555 vs $3081 and $2187, respectively) and more effective in terms of adverse events averted (0.9989 vs 0.9957 and 0.9947, respectively). The PSA confirmed our findings using both institutional costs and AWP. In conclusion, fondaparinux subcutaneous injection afforded significant advantages in terms of cost savings and adverse events averted compared with IV argatroban or bivalirudin infusions. Our data strongly suggest potential cost savings with fondaparinux and underscore the critical need for larger clinical studies of fondaparinux in the treatment of suspected HIT. (Blood. 2016;128(26):3043-3051)

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The Incidence of Recognized Heparin-Induced Thrombocytopenia in a Large, Tertiary Care Teaching Hospital

Cited by 156 publications

References 11 publications

How I treat patients with a history of heparin-induced thrombocytopenia

How I treat patients with a history of heparin-induced thrombocytopenia

Economic evaluation of dabigatran etexilate for the primary prevention of venous tromboembolic events following major orthopedic surgery in the Netherlands

Cost-effectiveness of anticoagulants for suspected heparin-induced thrombocytopenia in the United States

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