Guidelines
All lines of therapy
Argatroban monotherapy
Regimen
Note: In ALicia, only 15 patients (23%) in the study had confirmed HIT.
Anticoagulation
- ARG-911, ARG-915: Argatroban (Acova) 2 mcg/kg/min IV adjusted to maintain activated partial thromboplastin time 1.5 to 3.0 times baseline value.
- ALicia: Argatroban (Acova) without liver dysfunction: 0.5 mcg/kg/min IV adjusted to maintain activated partial thromboplastin time 1.5 to 2.0 times baseline value.
- ALicia: Argatroban (Acova) with severe liver dysfunction (bilirubin >4 mg/dL): 0.25 mcg/kg/min IV adjusted to maintain activated partial thromboplastin time 1.5 to 2.0 times baseline value.
References
- ARG-911: Lewis BE, Wallis DE, Berkowitz SD, Matthai WH, Fareed J, Walenga JM, Bartholomew J, Sham R, Lerner RG, Zeigler ZR, Rustagi PK, Jang IK, Rifkin SD, Moran J, Hursting MJ, Kelton JG; ARG-911 Study Investigators. Argatroban anticoagulant therapy in patients with heparin-induced thrombocytopenia. Circulation. 2001 Apr 10;103(14):1838-43. link to original article PubMed
- ARG-915: Lewis BE, Wallis DE, Leya F, Hursting MJ, Kelton JG; ARG-915 Study Investigators. Argatroban anticoagulation in patients with heparin-induced thrombocytopenia. Arch Intern Med. 2003;164:1849-1856. link to original article PubMed
- ALicia: Treschan TA, Schaefer MS, Geib J, Bahlmann A, Brezina, T, Werner P, Golla, E, Greinacher A, Pannen B, Kindgen-Milles D, Kienbaum P, Beiderlinden M. Argatroban versus lepirudin in critically ill patients (ALicia): a randomized controlled trial. Critical Care. 2014 Oct 25;18(5):588. link to original article link to PMC article PubMed
- Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015 Feb 5;125(6):924-9. link to original article PubMed
Danaparoid monotherapy
Regimen
Anticoagulation
- Danaparoid (Orgaran) 2400 anti-Xa units IV bolus once, then 400 units per hour for 2h, 300 units per hour for 2h, and then 200 units per hour for five days.
References
- Chong BH, Gallus AS, Cade JF, Magnani H, Manoharan A, Oldmeadow M, Arthur C, Rickard K, Gallo J, Lloyd J, Seshadri P, Chesterman CN; Australian HIT Study Group. Prospective randomised open-label comparison of danaparoid with dextran 70 in the treatment of heparin-induced thrombocytopaenia with thrombosis: a clinical outcome study. Thromb Haemost. 2001 Nov;86(5):1170-5. link to original article PubMed
- Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015 Feb 5;125(6):924-9. link to original article PubMed
Fondaparinux monotherapy
Regimen
To be completed
Anticoagulation
References
- Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015 Feb 5;125(6):924-9. link to original article PubMed
Lepirudin monotherapy
Regimen
Note: Only 15 patients (23%) in the study had confirmed HIT.
Anticoagulation
- Lepirudin (Refludan) as follows:
- Patients with continuous renal replacement therapy: 5 mcg/kg/hr IV adjusted to maintain activated partial thromboplastin time 1.5 to 2.0 times baseline value.
- Patients with moderate renal impairment (creatinine 1.3 mg/dl or more): 10 mcg/kg/hr IV adjusted to maintain activated partial thromboplastin time 1.5 to 2.0 times baseline value.
- Patients with without renal impairment (creatinine less than 1.3 mg/dl): 50 mcg/kg/hr IV adjusted to maintain activated partial thromboplastin time 1.5 to 2.0 times baseline value.
References
- ALicia: Treschan TA, Schaefer MS, Geib J, Bahlmann A, Brezina, T, Werner P, Golla, E, Greinacher A, Pannen B, Kindgen-Milles D, Kienbaum P, Beiderlinden M. Argatroban versus Lepirudin in critically ill patients (ALicia): a randomized controlled trial. Critical Care. 2014 Oct 25;18(5):588. link to original article link to PMC article PubMed
Rivaroxaban monotherapy
Regimen
Note: In the first prospective study of DOACs in HIT by Linkins, 22 patients were enrolled with suspected HIT. The overall symptomatic recurrent VTE rate was 4.5% (1 patient out of 22), but only 12 of the patients were confirmed to have HIT. The thrombotic event rate among HIT-positive participants was 8.3%. The study was stopped early due to slow accrual but had enrolled the minimum required number of HIT patients.
Anticoagulation
- Rivaroxaban (Xarelto): 15 mg PO twice per day until platelet recovery (or until day 21 if acute thrombosis present at study entry), then 20mg daily until day 30
References
- Linkins LA, Warkentin TE, Pai M, Shivakumar S, Manji RA, Wells PS, Wu C, Nazi I, Crowther MA. Rivaroxaban for treatment of suspected or confirmed heparin-induced thrombocytopenia study. J Thromb Haemost. 2016 Jun;14(6):1206-10. link to original article PubMed