Badr_2013 Clinical Practice Guidline on Evaluation and Management of Adults With Suspected Heparin Induced Trombocytopenia

5/21/2018 Badr_2013 Clinical Practice Guidline on Evaluation and Management of Adults With Suspected Heparin Induced Trombocytopenia

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2013 Clinical Practice

Guideline on the

Evaluation and

Management of

Adults with Suspected

Heparin-Induced

Thrombocytopenia (HIT)

Adam Cuker1and Mark A. Crowther2

1University of Pennsylvania, Philadelphia,

PA; 2St. Josephs Hospital and McMaster

University, Hamilton, ON, Canada

Presented by the American Society ofHematology, adapted in part from: Treatment

and prevention of heparin-

induced thrombocytopenia:

American College of Chest

Physicians Evidence-Based

Clinical Practice Guidelines

(9thEdition)

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I. History and Physical Examination:

Evaluating the Clinical Probability of HIT

A. Features of the history and physical examination that support adiagnosis of HIT

Feature Comments

Fall in platelet count50% From highest platelet count after heparinexposure; platelet count fall is 3050% in 10%

of cases

Fall in platelet count begins514 days after immunizingheparin exposure

Heparin administered during or soon aftersurgery is more likely to be immunizing

Fall in platelet count beginswithin 24 hours after heparinexposure

May occur in patients with previous heparinexposure within last 100 days

Nadir platelet count20 x 109/L

Nadir may exceed lower limit of normal range(i.e. 150 x 109/L ) in patients with high baselineplatelet counts. May be 50% andplatelet nadir20x 109/L

Platelet countfall 3050% orplatelet nadir 10-19 x 109/L

Platelet count fall


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IV. Treatment

A. Non-heparin anticoagulants: selection, dosing, and monitoring

Agent Initial dosing Monitoring

Argatroban Bolus: NoneContinuous infusion:

Normal organ function2 mcg/kg/min1

Liver dysfunction (total serum

bilirubin>1.5 mg/dL), heartfailure, post-cardiac surgery,anasarca0.51.2 mcg/kg/min2

Adjust dose to APTT of1.53.0 times patient baseline.Monitor APTT every 4 hoursduring dose titration.

Danaparoid3 Bolus:Weight90 kg3750 UAccelerated initial infusion:

400 U/hr x 4 hrs, then 300 U/hr x 4 hrsMaintenance infusion:

Cr 4 4. Repeat INR in 46 hours 5. If INR is


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American Society of Hematology2021 L Street NW, Suite 900

Washington, DC 20036

www.hematology.org

V. Heparin Reexposure in Patients

with a History of HIT

A. Cardiac and vascular surgery In patients with a history of HIT, laboratory testing may be used

to determine whether HIT is acute, subacute, or remote and thesafety of using intraoperative heparin.

Clinical

picture

Laboratory profile Recommended intraoperative

anticoagulation1, 2

Platelet

count

Immuno-

logic assay

RemoteHIT

Recovered Negative 1. Use UFH (Grade 2C)

Sub-acuteHIT

Recovered Positive 1. Delay surgery, if possible, until immuno-logic assay becomes negative (Grade 2C)2. If surgery cannot be delayed, use bivaliru-din (Grade 2C)3

AcuteHIT

Thrombo-cytopenic

Positive 1. Delay surgery, if possible, until functionaland immunologic assays become negative(Grade 2C)2. If surgery cannot be delayed, use bivaliru-din (Grade 2C)3. Case reports suggest that repeatedplasmapheresis may transiently reduce HITantibody levels, allowing brief heparin re-

exposure during surgery4

1If heparin is given, it should be limited to the intraoperative setting. If pre- orpostoperative anticoagulation is indicated, a non-heparin anticoagulant should beused and heparin exposure scrupulously avoided.2American College of Chest Physicians Grading System: 1, strong recommendation;2, weak recommendation; A, based on high quality evidence; B, based on moderatequality evidence; C, based on low quality evidence.3Small studies suggest UFH may be used for intraoperative anticoagulation inpatients with subacute HIT provided that the functional assay has become negative.4Grade 2C per the American Society of Apheresis (Schwartz et al., J Clin Apheresis2013;28:145).UFH, unfractionated heparin, is an important option in centers where experience withintraoperative bivalirudin is limited.

B. Cardiac catheterization/percutaneous coronary intervention

Clinical

picture

Laboratory profile Recommended

intraprocedural

anticoagulation1

Platelet

count

Immunologic

assay

RemoteHIT

Recovered Negative 1. Use bivalirudin (Grade 2B)or argatroban (Grade 2C)2. If a non-heparin anticoagu-lant is not available, use UFH

SubacuteHIT

Recovered Positive 1. Use bivalirudin (Grade 2B)or argatroban (Grade 2C)

Acute HIT Thrombocy-topenic

Positive

1American College of Chest Physicians Grading System: 1, strong recommendation;2, weak recommendation; A, based on high quality evidence; B, based on moderatequality evidence; C, based on low quality evidence.

This document summarizes selected recommendations from: Treatand prevention of heparin-induced thrombocytopenia: American Coof Chest Physicians Evidence-Based Clinical Practice Guidelines(9thEdition).

Guidelines provide the practitioner with clear principles and strategquality patient care and do not establish a fixed set of rules that prephysician judgment.

For further information, please see the complete guidelines on the Cwebsite at www.chestjournal.org/content/133/6_suppl/340S.longrefer to the Practice Guidelines section of the ASH website atwww.hematology.org/practiceguidelines. You may also contact theASH Government Affairs, Practice, and Scientific Affairs Departmeat 202-776-0544.

Cover Image: In vivomicroscopy showing monocytes (in red), platelets (in grand areas of overlap (in yellow) being incorporated into a growing thrombus mouse model of HIT. Courtesy of L. Rauova and M. Poncz, Childrens HospitPhiladelphia.

2013 Clinical Practice Guideline on the Evaluation and Management of Adults with Suspected Heparin-Induced Thrombocytopenia (HIT) pa

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Badr_2013 Clinical Practice Guidline on Evaluation and Management of Adults With Suspected Heparin Induced Trombocytopenia