From the Guidelines
For patients with a history of heparin-induced thrombocytopenia (HIT) who require DVT prophylaxis, non-heparin anticoagulants such as argatroban, bivalirudin, fondaparinux, or direct oral anticoagulants (DOACs) like rivaroxaban are recommended instead of heparin products. According to the American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia 1, the choice of agent may be influenced by drug factors, patient factors, and experience of the clinician.
Key Considerations
- Argatroban (typical dose 0.5-2 μg/kg/min IV) or bivalirudin (0.15-0.2 mg/kg/hr IV) may be preferred in patients with acute HIT or critical illness due to their short half-lives and ability to be monitored with aPTT 1.
- Fondaparinux (2.5 mg subcutaneously daily) or oral DOACs like rivaroxaban (10 mg daily) are reasonable options in clinically stable patients at average risk of bleeding 1.
- Renal function must be assessed before using fondaparinux or oral anticoagulants as they require dose adjustments or avoidance in severe renal impairment 1.
- Platelet counts should be monitored during the first few days of therapy even with non-heparin anticoagulants 1.
Rationale
The recommendation to use non-heparin anticoagulants is based on the high risk of recurrent thrombosis and the potential for life-threatening complications associated with re-exposure to heparin products in patients with a history of HIT 1. The choice of agent should be individualized based on patient-specific factors, including renal function, liver function, bleeding risk, and clinical stability 1.
Monitoring and Follow-up
Regular monitoring of platelet counts and renal function is essential to minimize the risk of adverse events and ensure the safe use of non-heparin anticoagulants in patients with a history of HIT 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
DVT Prophylaxis in Patients with a History of HIT
- Patients with a history of heparin-induced thrombocytopenia (HIT) require alternative anticoagulation for DVT prophylaxis due to the risk of recurrent HIT 2.
- Fondaparinux, a non-heparin anticoagulant, has been shown to be effective and safe for DVT prophylaxis in patients with a history of HIT 3, 4.
- The use of fondaparinux for HIT treatment is supported by studies, which demonstrate its effectiveness in preventing thrombosis and major bleeding 3, 4.
- However, the risk of fondaparinux-associated HIT, although low, is real, and its use should be cautious 5.
- Other non-heparin anticoagulants, such as argatroban, danaparoid, and direct oral anticoagulants (DOACs), may also be considered for DVT prophylaxis in patients with a history of HIT 2, 6.
- The choice of anticoagulant should be individualized based on patient factors, such as renal function and bleeding risk 6, 4.
Considerations for Fondaparinux Use
- Fondaparinux has been used successfully in patients with severe renal impairment, but its use in this population requires careful consideration and individualized dosing 4.
- The use of fondaparinux is contraindicated in patients with severe renal insufficiency, and alternative anticoagulants should be considered in these cases 6.
- Fondaparinux has been shown to be effective in preventing thrombosis and major bleeding in patients with a history of HIT, but its use should be monitored closely due to the risk of fondaparinux-associated HIT 3, 5.