What is the recommended Deep Vein Thrombosis (DVT) prophylaxis in someone with Heparin-Induced Thrombocytopenia (HIT)?

From the Guidelines

For DVT prophylaxis in someone with HIT, a non-heparin anticoagulant such as argatroban, bivalirudin, danaparoid, fondaparinux, or a direct oral anticoagulant (DOAC) should be used instead of heparin products. When selecting a non-heparin anticoagulant, the choice of agent may be influenced by drug factors, patient factors, and experience of the clinician 1. In patients with critical illness, increased bleeding risk, or increased potential need for urgent procedures, argatroban or bivalirudin may be preferred because of their shorter duration of effect, and these patients may require close monitoring 1. Some key points to consider when choosing an anticoagulant include:

• Argatroban or bivalirudin may be preferred in patients with critical illness or increased bleeding risk
• Fondaparinux and DOACs are reasonable options in clinically stable patients at average risk of bleeding
• The same contraindications to their use in the treatment of acute VTE should be applied in determining their appropriateness for patients with HIT
• Rivaroxaban at a dose of 15 mg twice per day for 3 weeks followed by 20 mg once per day is preferred for patients with acute HITT, and rivaroxaban 15 mg twice per day until platelet count recovery followed by 20 mg once per day is preferred for patients with acute isolated HIT if there is an indication for ongoing anticoagulation 1. It is essential to avoid all heparin products, including heparin flushes and heparin-coated catheters, to prevent potentially life-threatening thrombotic complications in patients with HIT 1. Regular monitoring of platelet counts is also crucial during treatment with non-heparin anticoagulants in patients with HIT 1.

From the FDA Drug Label

1 INDICATIONS & USAGE

1.1 Heparin-Induced Thrombocytopenia Argatroban Injection is indicated for prophylaxis or treatment of thrombosis in adult patients with heparin-induced thrombocytopenia (HIT).

• Argatroban can be used for DVT prophylaxis in someone with HIT.
• The drug label directly supports the use of argatroban for prophylaxis of thrombosis, including DVT, in patients with HIT 2.

From the Research

DVT Prophylaxis in Someone with HIT

• The management of heparin-induced thrombocytopenia (HIT) requires the use of non-heparin anticoagulant therapy, as heparin can exacerbate the condition 3, 4.
• Argatroban is a commonly used anticoagulant for the treatment of HIT, and has been shown to have superior outcomes compared to other anticoagulants such as lepirudin, desirudin, bivalirudin, and danaparoid 5.
• Fondaparinux is also used as an off-label treatment for HIT, but its use is contraindicated in patients with severe renal insufficiency 3, 4.
• Direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, and dabigatran have been emerging as potential treatment options for HIT, but their use should be reserved for clinically stable patients without severe thrombotic complications 3, 4.
• The selection of anticoagulant therapy for HIT should be based on individual patient characteristics, institutional resources, and the presence of any contraindications or precautions 6.

Anticoagulant Options

• Argatroban: a parenteral anticoagulant that requires close monitoring and has been shown to have superior outcomes in patients with HIT 5.
• Fondaparinux: a parenteral anticoagulant that is used off-label for the treatment of HIT, but is contraindicated in patients with severe renal insufficiency 3, 4.
• DOACs: a class of oral anticoagulants that have been emerging as potential treatment options for HIT, but should be used with caution and only in clinically stable patients without severe thrombotic complications 3, 4.

Considerations for DVT Prophylaxis

• Patients with HIT are at increased risk of thrombotic complications, and therefore require careful consideration of anticoagulant therapy to prevent deep vein thrombosis (DVT) 7.
• The selection of anticoagulant therapy for DVT prophylaxis in patients with HIT should be based on individual patient characteristics, institutional resources, and the presence of any contraindications or precautions 6.