From the Guidelines
To avoid heparin-induced thrombocytopenia (HIT), argatroban, bivalirudin, danaparoid, fondaparinux, or a direct oral anticoagulant (DOAC) such as rivaroxaban are recommended as alternative anticoagulants. The choice of agent may be influenced by drug factors, patient factors, and experience of the clinician 1.
Key Considerations
- Argatroban is administered intravenously with an initial dose of 2 mcg/kg/min, adjusted based on aPTT.
- Bivalirudin is given at 0.15-0.2 mg/kg/hr for most indications.
- Fondaparinux is administered subcutaneously at 5-10 mg daily based on weight.
- For oral options, DOACs like apixaban, rivaroxaban, edoxaban, and dabigatran can be used once the platelet count has recovered.
Mechanism and Monitoring
These medications work by directly inhibiting thrombin or factor Xa without requiring antithrombin as a cofactor, unlike heparin products, which explains why they don't cause HIT 1.
Transitioning to Oral Anticoagulation
When transitioning from parenteral to oral anticoagulation, overlap therapy is typically needed for 24-48 hours to ensure adequate anticoagulation. Platelet count monitoring should continue until recovery is confirmed, even after switching to non-heparin anticoagulants 1.
Specific Recommendations
In patients with HIT complicated by life- or limb-threatening thromboembolism, a parenteral non-heparin anticoagulant may be preferred, and for patients with acute HITT, rivaroxaban at a dose of 15 mg twice per day for 3 weeks followed by 20 mg once per day is preferred 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). 1.2 Percutaneous Coronary Intervention Argatroban Injection is indicated as an anticoagulant in adult patients with or at risk for HIT undergoing percutaneous coronary intervention (PCI).
To avoid Heparin-Induced Thrombocytopenia (HIT), the anticoagulant that can be used is Argatroban, as it is specifically indicated for prophylaxis or treatment of thrombosis in adult patients with HIT 2.
- Key points:
- Argatroban is used for patients with HIT
- Argatroban can be used for patients at risk for HIT undergoing percutaneous coronary intervention (PCI)
From the Research
Anticoagulants Used to Avoid Heparin-Induced Thrombocytopenia (HIT)
To avoid HIT, several anticoagulants can be used as alternatives to heparin. These include:
- Argatroban: a direct thrombin inhibitor that has been shown to be effective in managing HIT 3, 4, 5, 6
- Lepirudin: a direct thrombin inhibitor that is approved for the management of HIT in the United States 7
- Bivalirudin: a direct thrombin inhibitor that is approved for use in patients with HIT who are undergoing percutaneous coronary intervention 7, 6
- Danaparoid: an anticoagulant that has been used to manage HIT, although its role in therapy requires further evaluation 7
- Desirudin: an anticoagulant that has been used to manage HIT, although its role in therapy requires further evaluation 4
Comparison of Anticoagulants
Studies have compared the efficacy and safety of these anticoagulants in managing HIT. For example:
- A Bayesian network meta-analysis found that argatroban had the shortest hospitalization length and the lowest rate of major and minor hemorrhagic events, thromboembolic events, and mortality compared to other anticoagulants 4
- A retrospective analysis found that argatroban was associated with a lower risk of thrombosis and mortality compared to historical control therapy 3
- A multicenter clinical trial found that argatroban was effective in managing HIT in patients with renal failure or at high hemorrhagic risk 5
- A single-center, retrospective, observational cohort study found that argatroban was associated with a faster time to therapeutic anticoagulation compared to bivalirudin 6
Special Considerations
When using these anticoagulants to avoid HIT, special considerations must be taken into account, such as:
- Patient population: certain patient populations, such as those undergoing coronary artery bypass surgery or with acute coronary syndromes, may require special attention 7
- Renal or hepatic insufficiency: patients with renal or hepatic insufficiency may require dose adjustments or alternative anticoagulants 7, 5
- Bleeding risk: patients at high risk of bleeding may require closer monitoring and dose adjustments 5