From the Guidelines
Discontinuing heparin therapy and switching to a nonheparin anticoagulant is the critical step in the management of Heparin-Induced Thrombocytopenia (HIT).
Management of HIT
- The management of HIT involves the use of nonheparin anticoagulants, such as argatroban, bivalirudin, or danaparoid 1.
- Direct oral anticoagulants (DOACs), such as rivaroxaban and apixaban, may also be considered as alternative anticoagulants in select cases, although they are not currently licensed for patients with HIT 1.
- Intravenous immunoglobulin (IVIg) may be used in the management of spontaneous, persistent, and treatment-refractory HIT 1.
Key Considerations
- Discontinuation of heparin therapy is essential in the management of HIT, and should be done immediately upon suspicion of the condition 1.
- Alternative anticoagulants should be started as soon as possible after discontinuation of heparin therapy 1.
- Biological confirmation of the diagnosis is necessary in all cases, but should not delay the stopping of heparin and the prescription of an alternative anticoagulant 1.
Treatment Options
- Argatroban: a direct thrombin inhibitor that can be used as an alternative anticoagulant in patients with HIT 1.
- Bivalirudin: a direct thrombin inhibitor that can be used as an alternative anticoagulant in patients with HIT 1.
- Danaparoid: a heparinoid that can be used as an alternative anticoagulant in patients with HIT 1.
- Rivaroxaban: a DOAC that may be considered as an alternative anticoagulant in select cases of HIT 1.
- Apixaban: a DOAC that may be considered as an alternative anticoagulant in select cases of HIT 1.
From the Research
Management of Heparin-Induced Thrombocytopenia (HIT)
The management of HIT involves several key steps, including:
- Discontinuation of heparin therapy as soon as HIT is suspected 2, 3, 4, 5
- Initiation of non-heparin anticoagulation therapy to prevent further thrombotic complications 2, 3, 6, 4, 5
- Use of risk-stratification tools and laboratory assays to confirm the diagnosis of HIT 3, 5
- Selection of appropriate non-heparin anticoagulants, such as direct-acting oral anticoagulants (DOACs), parenteral thrombin inhibitors, or parenteral factor Xa inhibitors 2, 6, 4
Non-Heparin Anticoagulants
The use of non-heparin anticoagulants in HIT management includes:
- DOACs, such as rivaroxaban, apixaban, and dabigatran, which may be used in acute HIT, but should be reserved for clinically stable patients without severe thrombotic complications 2, 4
- Parenteral thrombin inhibitors, such as argatroban and bivalirudin, which are approved for HIT treatment in some countries 4
- Parenteral factor Xa inhibitors, such as danaparoid and fondaparinux, which may be used off-label for HIT treatment 4
Treatment Strategies
Treatment strategies for HIT may vary depending on the phase of HIT, including:
- Suspected, acute, subacute A and B, and remote HIT, which require different management approaches 2
- Use of therapeutic-intensity anticoagulation, which may be more effective than prophylactic-intensity anticoagulation 6
- Avoidance of inferior vena cava filters and platelet transfusion, which may result in greater harm than benefit 6