From the Guidelines
For patients with heparin-induced thrombocytopenia (HIT) who need an alternative to fondaparinux, argatroban or bivalirudin are recommended as first-line options. According to the American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia 1, when a non-heparin anticoagulant is being selected, the guideline panel suggests argatroban, bivalirudin, danaparoid, or a direct oral anticoagulant (DOAC) as alternatives. Some key points to consider when choosing an alternative to fondaparinux include:
- The choice of agent may be influenced by drug factors (availability, cost, ability to monitor the anticoagulant effect, route of administration, and half-life), patient factors (kidney function, liver function, bleeding risk, and clinical stability), 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 1.
- Fondaparinux and the DOACs are reasonable options in clinically stable patients at average risk of bleeding, with the same contraindications to their use in the treatment of acute VTE applied in determining their appropriateness for patients with HIT 1.
- For oral therapy, DOACs like rivaroxaban (15-20 mg daily) can be used once platelets recover above 150,000/μL, with a preferred dosing regimen of 15 mg twice per day for 3 weeks followed by 20 mg once per day for patients with acute HITT 1.
From the Research
Fondaparinux as an Alternative in HIT
- Fondaparinux may be used as an alternative anticoagulant in patients with heparin-induced thrombocytopenia (HIT) [(2,3,4,5,6)].
- Studies have shown that fondaparinux has similar effectiveness and safety as argatroban and danaparoid in patients with suspected HIT 2.
- Fondaparinux has been successfully used in patients with HIT, including those with severe renal impairment 3.
Comparison with Other Anticoagulants
- Argatroban is currently the only anticoagulant with regulatory approval for HIT treatment in both the US and Europe 4.
- Fondaparinux and direct oral anticoagulants (DOACs) are being used off-label for HIT treatment, with emerging evidence supporting their use [(4,6)].
- The choice of anticoagulant should be individualized based on patient factors, such as renal function and presence of thrombosis 5.
Important Considerations
- Fondaparinux is not formally approved by the US Food and Drug Administration for HIT treatment 5.
- Fondaparinux and DOACs are contraindicated in severe renal insufficiency 4.
- Close monitoring and individualized dosing are necessary when using fondaparinux or other anticoagulants in patients with HIT [(2,3,5)].