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Warkentin TE. Autoimmune Heparin-Induced Thrombocytopenia. J Clin Med 2023; 12:6921. [PMID: 37959386 PMCID: PMC10649402 DOI: 10.3390/jcm12216921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/27/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
Autoimmune thrombocytopenia (aHIT) is a severe subtype of heparin-induced thrombocytopenia (HIT) with atypical clinical features caused by highly pathological IgG antibodies ("aHIT antibodies") that activate platelets even in the absence of heparin. The clinical features of aHIT include: the onset or worsening of thrombocytopenia despite stopping heparin ("delayed-onset HIT"), thrombocytopenia persistence despite stopping heparin ("persisting" or "refractory HIT"), or triggered by small amounts of heparin (heparin "flush" HIT), most cases of fondaparinux-induced HIT, and patients with unusually severe HIT (e.g., multi-site or microvascular thrombosis, overt disseminated intravascular coagulation [DIC]). Special treatment approaches are required. For example, unlike classic HIT, heparin cessation does not result in de-escalation of antibody-induced hemostasis activation, and thus high-dose intravenous immunoglobulin (IVIG) may be indicated to interrupt aHIT-induced platelet activation; therapeutic plasma exchange may be required if high-dose IVIG is ineffective. Also, aHIT patients are at risk for treatment failure with (activated partial thromboplastin time [APTT]-adjusted) direct thrombin inhibitor (DTI) therapy (argatroban, bivalirudin), either because of APTT confounding (where aHIT-associated DIC and resulting APTT prolongation lead to systematic underdosing/interruption of DTI therapy) or because DTI inhibits thrombin-induced protein C activation. Most HIT laboratories do not test for aHIT antibodies, contributing to aHIT under-recognition.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; ; Tel.: +1-(905)-527-0271 (ext. 46139)
- Service of Benign Hematology, Hamilton Health Sciences (General Site), Hamilton, ON L8L 2X2, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, ON L8L 2X2, Canada
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Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated condition causing thrombocytopenia and paradoxical thrombosis after exposure to heparin or low-molecular-weight heparin. It has been rarely reported by Fondaparinux, an artificial pentasaccharide similar to heparin. This manuscript presents a case of HIT associated with fondaparinux use.
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Affiliation(s)
- Jahanzeb Malik
- Dr. Jahanzeb Malik, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan
| | - Nismat Javed
- Dr. Nismat Javed, Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Matiullah Kamin
- Dr. Matiullah Kamin, Shifa International Hospital, Islamabad, Pakistan
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Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med 2020; 25:160-173. [PMID: 32195628 DOI: 10.1177/1358863x19898253] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
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Affiliation(s)
- Marie Hogan
- Department of Pediatrics, Division of Hematology Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology and Hematology, New York University School of Medicine, New York, NY, USA
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Roberge G, Tritschler T, MacGillivray C, Dufresne L, Nagpal SK, Scarvelis D. Persisting autoimmune heparin-induced thrombocytopenia after elective abdominal aortic aneurysm repair: a case report. J Thromb Thrombolysis 2020; 50:674-677. [DOI: 10.1007/s11239-020-02062-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Jin J, Baker SA, Hall ET, Gombar S, Bao A, Zehnder JL. Implementation of Whole-Blood Impedance Aggregometry for Heparin-Induced Thrombocytopenia Functional Assay and Case Discussion. Am J Clin Pathol 2019; 152:50-58. [PMID: 31165165 DOI: 10.1093/ajcp/aqz013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The diagnosis of heparin-induced thrombocytopenia (HIT) ideally requires a functional assay to confirm. 14C-serotonin release assay (SRA) as "gold standard" is technically challenging and unsuitable for routine use. We conducted a study to assess the performance of whole-blood impedance aggregometry (WBIA) as a simple and rapid HIT functional assay. METHODS Platelet factor 4 (PF4)/immunoglobulin G (IgG) antibody, WBIA, and SRA were tested on 70 patients suspected of having HIT. Patients with a 4Ts score of 4 or more, positive PF4/IgG, and positive SRA were considered HIT positive; others were designated HIT negative. RESULTS WBIA had 85.7% (6/7) sensitivity and 98.4% (61/62) specificity, which were not statistically different compared with SRA. Sixty-two of 70 patients had concordant results (five positive and 57 negative) by both WBIA and SRA. Eight discordant cases revealed the importance of recognizing donor effect, interferences, and the presence of heparin-independent or non-heparin-dependent antibodies in functional assays. CONCLUSIONS Implementation of WBIA could facilitate timely diagnosis and management of HIT.
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Affiliation(s)
- Jing Jin
- Department of Special Coagulation, Clinical Laboratory, Stanford Medical Center, Stanford, CA
| | | | - Evan T Hall
- Division of Hematology, School of Medicine, Stanford University, Stanford, CA
| | - Saurabh Gombar
- Department of Pathology, Stanford University, Stanford, CA
| | | | - James L Zehnder
- Department of Pathology, Stanford University, Stanford, CA
- Division of Hematology, School of Medicine, Stanford University, Stanford, CA
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Mohanty E, Nazir S, Sheppard JAI, Forman DA, Warkentin TE. High-dose intravenous immunoglobulin to treat spontaneous heparin-induced thrombocytopenia syndrome. J Thromb Haemost 2019; 17:841-844. [PMID: 30773806 DOI: 10.1111/jth.14411] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Indexed: 01/28/2023]
Abstract
Essentials Spontaneous HIT syndrome clinically/serologically resembles HIT but without proximate heparin. Rarely, spontaneous HIT syndrome complicates total knee arthroplasty surgery. Mesenteric vein thrombosis is a rare presentation of spontaneous HIT syndrome. IVIg rapidly corrects thrombocytopenia by inhibiting heparin-independent platelet activation. SUMMARY: Spontaneous heparin-induced thrombocytopenia (HIT) syndrome is an autoimmune HIT (aHIT) disorder characterized by thrombocytopenia, thrombosis, and HIT antibodies despite no proximate heparin exposure. For unknown reasons, many cases occur after total knee arthroplasty. A 52-year-old woman presented 12 days posttotal knee replacement (aspirin thromboprophylaxis) with gastrointestinal bleeding (superior mesenteric vein thrombosis); the platelet count was 63 × 109 L-1 . After bowel resection and a brief course of heparin, treatment was changed to argatroban followed by fondaparinux. In addition, high-dose intravenous immunoglobulin (IVIg), 1 g kg-1 on 2 consecutive days, resulted in abrupt platelet count rise from 21 (nadir) pre-IVIg to 137 (post-IVIg), and 2 days later to 200 × 109 L-1 . Heparin-independent serum-induced serotonin-release abruptly decreased from 91% (pre-IVIg) to 14% (post-IVIg); although serotonin-release later rebounded to 49%, the patient's platelet counts remained normal. Our observations support the emerging concept that high-dose IVIg is effective for treating aHIT disorders, including spontaneous HIT syndrome.
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Affiliation(s)
| | - Salik Nazir
- Reading Health System, West Reading, PA, USA
| | - Jo-Ann I Sheppard
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
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Arcinas LA, Manji RA, Hrymak C, Dao V, Sheppard JAI, Warkentin TE. Autoimmune heparin-induced thrombocytopenia and venous limb gangrene after aortic dissection repair: in vitro and in vivo effects of intravenous immunoglobulin. Transfusion 2019; 59:1924-1933. [PMID: 30903805 DOI: 10.1111/trf.15263] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/19/2019] [Accepted: 02/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a prothrombotic disorder characterized by heparin-dependent antibodies that activate platelets (PLTs) via PLT FcγIIa receptors. "Autoimmune" HIT (aHIT) indicates a HIT subset where thrombocytopenia progresses or persists despite stopping heparin; aHIT sera activate PLTs strongly even in the absence of heparin (heparin-independent PLT-activating properties). Affected patients are at risk of severe complications, including dual macro- and microvascular thrombosis leading to venous limb gangrene. High-dose intravenous immunoglobulin (IVIG) offers an approach to interrupt heparin-independent PLT-activating effects of aHIT antibodies. CASE REPORT A 78-year-old male who underwent cardiopulmonary bypass for aortic dissection developed aHIT, disseminated intravascular coagulation, and deep vein thrombosis; progression to venous limb gangrene occurred during partial thromboplastin time (PTT)-adjusted bivalirudin infusion (underdosing from "PTT confounding"). Thrombocytopenia recovered with high-dose IVIG, although the PLT count increase began only after the third dose of a 5-day IVIG regimen (0.4 g/kg/day × 5 days). We reviewed case reports and case series of IVIG for treating HIT, focusing on various IVIG dosing regimens used. RESULTS Patient serum-induced PLT activation was inhibited in vitro by IVIG in a dose-dependent fashion; inhibition of PLT activation by IVIG was much more marked in the absence of heparin versus the presence of heparin (0.2 U/mL). Our literature review indicated 1 g/kg × 2 IVIG dosing as most common for treating HIT, usually associated with rapid PLT count recovery. CONCLUSION Our clinical and laboratory observations support dose-dependent efficacy of IVIG for decreasing PLT activation and thus correcting thrombocytopenia in aHIT. Our case experience and literature review suggests dosing of 1 g/kg IVIG × 2 for patients with severe aHIT.
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Affiliation(s)
- Liane A Arcinas
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Section of Cardiac Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carmen Hrymak
- Section of Critical Care, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Vi Dao
- Section of Hematology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jo-Ann I Sheppard
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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Greinacher A, Selleng K, Warkentin TE. Autoimmune heparin-induced thrombocytopenia. J Thromb Haemost 2017; 15:2099-2114. [PMID: 28846826 DOI: 10.1111/jth.13813] [Citation(s) in RCA: 280] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Indexed: 01/18/2023]
Abstract
Autoimmune heparin-induced thrombocytopenia (aHIT) indicates the presence in patients of anti-platelet factor 4 (PF4)-polyanion antibodies that are able to activate platelets strongly even in the absence of heparin (heparin-independent platelet activation). Nevertheless, as seen with serum obtained from patients with otherwise typical heparin-induced thrombocytopenia (HIT), serum-induced platelet activation is inhibited at high heparin concentrations (10-100 IU mL-1 heparin). Furthermore, upon serial dilution, aHIT serum will usually show heparin-dependent platelet activation. Clinical syndromes associated with aHIT include: delayed-onset HIT, persisting HIT, spontaneous HIT syndrome, fondaparinux-associated HIT, heparin 'flush'-induced HIT, and severe HIT (platelet count of < 20 × 109 L-1 ) with associated disseminated intravascular coagulation (DIC). Recent studies have implicated anti-PF4 antibodies that are able to bridge two PF4 tetramers even in the absence of heparin, probably facilitated by non-heparin platelet-associated polyanions (chondroitin sulfate and polyphosphates); nascent PF4-aHIT-IgG complexes recruit additional heparin-dependent HIT antibodies, leading to the formation of large multimolecular immune complexes and marked platelet activation. aHIT can persist for several weeks, and serial fibrin, D-dimer, and fibrinogen levels, rather than the platelet count, may be helpful for monitoring treatment response. Although standard anticoagulant therapy for HIT ought to be effective, published experience indicates frequent failure of activated partial thromboplastin time (APTT)-adjusted anticoagulants (argatroban, bivalirudin), probably because of underdosing in the setting of HIT-associated DIC, known as 'APTT confounding'. Thus, non-APTT-adjusted therapies with drugs such as danaparoid and fondaparinux, or even direct oral anticoagulants, such as rivaroxaban or apixaban, are suggested therapies, especially for long-term management of persisting HIT. In addition, emerging data indicate that high-dose intravenous immunoglobulin can interrupt HIT antibody-induced platelet activation, leading to rapid platelet count recovery.
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MESH Headings
- Administration, Oral
- Animals
- Anticoagulants/administration & dosage
- Anticoagulants/adverse effects
- Anticoagulants/immunology
- Autoantibodies/blood
- Autoimmunity/drug effects
- Blood Coagulation/drug effects
- Blood Platelets/drug effects
- Blood Platelets/immunology
- Blood Platelets/metabolism
- Heparin/adverse effects
- Heparin/immunology
- Humans
- Immunoglobulins, Intravenous/administration & dosage
- Immunologic Factors/administration & dosage
- Partial Thromboplastin Time
- Platelet Activation/drug effects
- Platelet Factor 4/immunology
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
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Affiliation(s)
- A Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - K Selleng
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - T E Warkentin
- Department of Pathology and Molecular Medicine, Department of Medicine, and McMaster Centre for Transfusion Research, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent findings on heparin-induced thrombocytopenia (HIT), a prothrombotic disorder caused by platelet-activating IgG targeting platelet factor 4 (PF4)/polyanion complexes. RECENT FINDINGS HIT can explain unusual clinical events, including adrenal hemorrhages, arterial/intracardiac thrombosis, skin necrosis, anaphylactoid reactions, and disseminated intravascular coagulation. Sometimes, HIT begins/worsens after stopping heparin ('delayed-onset' HIT). Various HIT-mimicking disorders are recognized (e.g., acute disseminated intravascular coagulation/'shock liver' with limb ischemia). HIT has features of both B-cell and T-cell immune responses; uptake of PF4/heparin complexes into macrophages ('macropinocytosis') facilitates the anti-PF4/heparin immune response. Antibody-induced activation of monocytes and platelets via their FcγIIA receptors triggers an intense procoagulant response. Sometimes, HIT antibodies recognize PF4 bound to (platelet-associated) chondroitin sulfate, explaining how HIT might occur without concurrent or recent heparin (delayed-onset HIT, 'spontaneous HIT syndrome'). The molecular structure of HIT antigen(s) has been characterized, providing a rationale for future drug design to avoid HIT and improve its treatment. The poor correlation between partial thromboplastin time and plasma argatroban levels (risking subtherapeutic anticoagulation) and need for intravenous administration of argatroban have led to increasing 'off-label' treatment with fondaparinux or one of the direct oral anticoagulants. SUMMARY Understanding the molecular mechanisms and unusual clinical features of HIT will improve its management.
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Warkentin TE. Clinical picture of heparin-induced thrombocytopenia (HIT) and its differentiation from non-HIT thrombocytopenia. Thromb Haemost 2016; 116:813-822. [PMID: 27656712 DOI: 10.1160/th16-06-0435] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 08/12/2016] [Indexed: 12/14/2022]
Abstract
HIT is an acquired antibody-mediated disorder strongly associated with thrombosis, including microthrombosis secondary to disseminated intravascular dissemination (DIC). The clinical features of HIT are reviewed from the perspective of the 4Ts scoring system for HIT, which emphasises its characteristic timing of onset of thrombocytopenia. HIT antibodies recognize multimolecular complexes of platelet factor 4 (PF4)/heparin. However, a subset of HIT sera recognise PF4 bound to platelet chondroitin sulfate; these antibodies activate platelets in vitro and in vivo even in the absence of heparin, thus explaining: delayed-onset HIT (where HIT begins or worsens after stopping heparin); persisting HIT (where HIT takes several weeks to recover); spontaneous HIT syndrome (a disorder clinically and serologically resembling HIT but without proximate heparin exposure); and fondaparinux-associated HIT (four distinct syndromes featuring thrombocytopenia that begins or worsens during treatment with fondaparinux), with a new patient case presented with ongoing thrombocytopenia (and fatal haemorrhage) during treatment of HIT with fondaparinux, with fondaparinux-dependent platelet activation induced by patient serum ("fondaparinux cross-reactivity"). Ironically, despite existence of fondaparinux-associated HIT, this pentasaccharide anticoagulant is a frequent treatment for HIT (including one used by the author). HIT can be confused with other disorders, including those with a) timing similar to HIT (e. g. abciximab-associated thrombocytopenia of delayed-onset); b) combined thrombocytopenia/thrombosis (e. g. symmetrical peripheral gangrene secondary to acute DIC and shock liver); and c) both timing of onset and thrombosis (e. g. warfarin-associated venous limb gangrene complicating cancer-associated DIC). By understanding clinical and pathophysiological similarities and differences between HIT and non-HIT mimicking disorders, the clinician is better able to make the correct diagnosis.
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Affiliation(s)
- Theodore E Warkentin
- Prof. Theodore (Ted) E. Warkentin, Hamilton Regional Laboratory Medicine Program, Room 1-270B, Hamilton General Hospital, 237 Barton St. E., Hamilton, Ontario L8L 2X2, Canada, Tel.: +1 905 527 0271 ext. 46139, Fax: +1 905 577 1421, E-mail:
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Mulloy B, Hogwood J, Gray E, Lever R, Page CP. Pharmacology of Heparin and Related Drugs. Pharmacol Rev 2016; 68:76-141. [PMID: 26672027 DOI: 10.1124/pr.115.011247] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Heparin has been recognized as a valuable anticoagulant and antithrombotic for several decades and is still widely used in clinical practice for a variety of indications. The anticoagulant activity of heparin is mainly attributable to the action of a specific pentasaccharide sequence that acts in concert with antithrombin, a plasma coagulation factor inhibitor. This observation has led to the development of synthetic heparin mimetics for clinical use. However, it is increasingly recognized that heparin has many other pharmacological properties, including but not limited to antiviral, anti-inflammatory, and antimetastatic actions. Many of these activities are independent of its anticoagulant activity, although the mechanisms of these other activities are currently less well defined. Nonetheless, heparin is being exploited for clinical uses beyond anticoagulation and developed for a wide range of clinical disorders. This article provides a "state of the art" review of our current understanding of the pharmacology of heparin and related drugs and an overview of the status of development of such drugs.
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Affiliation(s)
- Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - John Hogwood
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - Rebecca Lever
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
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Girolami A, Cosi E, Tasinato V, Santarossa C, Ferrari S, Girolami B. Drug-Induced Thrombophilic or Prothrombotic States: An Underestimated Clinical Problem That Involves Both Legal and Illegal Compounds. Clin Appl Thromb Hemost 2016; 23:775-785. [DOI: 10.1177/1076029616652724] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Vascular thrombosis, both arterial and venous, is a condition associated with significant morbidity and mortality. There are multiple risk factors for thrombosis, both congenital and acquired, and in the majority of cases, these risk factors are not modifiable. Over the past 2 decades, multiple drugs (both illegal and legal) have been associated with increased risk of thrombosis. However, due to limited scientific literature regarding the prothrombotic tendencies of these drugs, there is a concomitant limited understanding of the pathophysiology of drug-induced thrombosis. As drugs are one of the few modifiable risk factors for thrombosis, further study and dissemination of knowledge regarding drug-associated and drug-induced thrombosis are essential and have the potential to lead to decreased future incidence of thrombosis. The mechanisms at the basis of the thrombophilic activity of these drugs are variable and sometimes still ill recognized. Increased levels of clotting factors, reduction in coagulation natural inhibitors, decreased fibrinolysis, activated clotting factors, increased blood viscosity, endothelial damage, and increased platelet number and activation are the most frequent causes. Arterial steal or coronary arteries no flow has also been implicated. In some cases due to the intake of several drugs, more than one mechanism is present in a given patient. The purpose of the present review is to analyze all the drugs demonstrated to be potentially thrombotic. It is hoped that a prudent use or nonuse of these drugs might result in a reduction of thrombosis-associated diseases.
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Affiliation(s)
- A. Girolami
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - E. Cosi
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - V. Tasinato
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - C. Santarossa
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - S. Ferrari
- Division of Medicine, University of Padua Medical School, Padua, Italy
| | - B. Girolami
- Division of Medicine, Padua City Hospital, Padua, Italy
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Wei M, Wang CT, Li DM, Song XJ. Prolonged use of fondaparinux for perioperative bridging: a case report of a patient with mechanical heart valve and heparin-induced thrombocytopenia. J Clin Pharm Ther 2015; 40:702-5. [PMID: 26573868 DOI: 10.1111/jcpt.12333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 10/08/2015] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Current guidelines provide no recommendations on perioperative bridging for patients after mechanical heart valve replacement (MHVR) who also have a history of heparin-induced thrombocytopenia (HIT). We present a successful case of prolonged bridging with fondaparinux in a 69-year-old Chinese woman. CASE SUMMARY The patient presented to our department with the aim for radical resection of oesophageal cancer. Fondaparinux has been administered alone at 2·5 mg subcutaneously once daily for 24 days during the interruption of warfarin perioperatively. There were no signs or symptoms of thromboembolic or bleeding throughout and after her hospitalization. WHAT IS NEW AND CONCLUSION Fondaparinux may offer an option for management of the patients with MHVR who cannot use heparin products, but further clinical investigations are warranted.
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Affiliation(s)
- M Wei
- Department of Pharmacy, Jinling Hospital, Nanjing, Jiangsu, China
| | - C T Wang
- Department of Cardio-thoracic Surgery, Jinling Hospital, Nanjing, Jiangsu, China
| | - D M Li
- Department of Cardio-thoracic Surgery, Jinling Hospital, Nanjing, Jiangsu, China
| | - X J Song
- Department of Pharmacy, Jinling Hospital, Nanjing, Jiangsu, China
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Sanidas EA, Viniou NA, Diamantopoulos P, Barbetseas J. Heparin induced thrombocytopenia. Contemporary therapeutic approaches in light of the new oral anticoagulants. Hamostaseologie 2015; 35:372-5. [PMID: 26302031 DOI: 10.5482/hamo-15-04-0013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/12/2015] [Indexed: 12/12/2022] Open
Abstract
Heparin induced thrombocytopenia (HIT) is a prothrombotic syndrome initiated by platelet-activating auto-antibodies with potentially devastating complications. Once the diagnosis of HIT is suspected, discontinuation of heparin and treatment with an alternative anticoagulant are mandatory. While established drugs for HIT are no longer available, parenteral factor Xa inhibitors, thrombin inhibitors and perhaps the direct oral anticoagulants provide additional treatment options. The aim of this review was to highlight the current clinical aspects regarding HIT focusing on the role of novel medications.
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Affiliation(s)
- E A Sanidas
- Elias Sanidas MD, PhD, FACC, FESC, Department of Cardiology, Laiko General Hospital, 17 Agiou Thoma street, 11527, Athens, Greece,
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Warkentin TE, Arnold DM, Nazi I, Kelton JG. The platelet serotonin-release assay. Am J Hematol 2015; 90:564-72. [PMID: 25775976 DOI: 10.1002/ajh.24006] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/05/2015] [Accepted: 03/08/2015] [Indexed: 12/24/2022]
Abstract
Few laboratory tests are as clinically useful as The platelet serotonin-release assay (SRA): a positive SRA in the appropriate clinical context is virtually diagnostic of heparin-induced thrombocytopenia (HIT), a life- and limb-threatening prothrombotic disorder caused by anti-platelet factor 4 (PF4)/heparin antibodies that activate platelets, thereby triggering serotonin-release. The SRA's performance characteristics include high sensitivity and specificity, although caveats include indeterminate reaction profiles (observed in ∼4% of test sera) and potential for false-positive reactions. As only a subset of anti-PF4/heparin antibodies detectable by enzyme-immunoassay (EIA) are additionally platelet-activating, the SRA has far greater diagnostic specificity than the EIA. However, requiring a positive EIA, either as an initial screening test or as an SRA adjunct, will reduce risk of a false-positive SRA (since a negative EIA in a patient with a "positive" SRA should prompt critical evaluation of the SRA reaction profile). The SRA also provides useful information on whether a HIT serum produces strong platelet activation even in the absence of heparin: such heparin-"independent" platelet activation is a marker of unusually severe HIT, including delayed-onset HIT and severe HIT complicated by consumptive coagulopathy with risk for microvascular thrombosis.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - Donald M. Arnold
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - Ishac Nazi
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
| | - John G. Kelton
- Department of Pathology and Molecular Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
- Department of Medicine; Michael G. DeGroote School of Medicine; McMaster University; Hamilton Ontario Canada
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