Treatment And Prevention Of Heparin-Induced Thrombocytopenia

Publication Date: February 1, 2012

Recommendations

Screening for HIT

For patients receiving heparin in whom clinicians consider the risk of HIT to be >1%, we suggest that platelet count monitoring be performed every 2 or 3 days from day 4 to day 14 (or until heparin is stopped, whichever occurs first). (2, C)
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For patients receiving heparin in whom clinicians consider the risk of HIT to be <1%, we suggest that platelet counts not be monitored. (2, C)
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Management of HIT Complicated by Thrombosis

In patients with HITT, we recommend the use of nonheparin anticoagulants, in particular lepirudin, argatroban, and danaparoid, over the further use of heparin or LMWH or initiation/continuation of VKA. (1, C)
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In patients with HITT who have normal renal function, we suggest the use of argatroban or lepirudin or danaparoid over other nonheparin anticoagulants. (2, C)
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In patients with HITT and renal insufficiency, we suggest the use of argatroban over other nonheparin anticoagulants. (2, C)
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In patients with HIT and severe thrombocytopenia, we suggest giving platelet transfusions only if bleeding or during the performance of an invasive procedure with a high risk of bleeding. (2, C)
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In patients with strongly suspected or confirmed HIT, we recommend against starting VKA until platelets have substantially recovered (ie, usually to at least 150 3 109 /L) over starting VKA at a lower platelet count and that the VKA be initially given in low doses (maximum, 5 mg of warfarin or 6 mg phenprocoumon) over using higher doses. (1, C)
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We further suggest that if a VKA has already been started when a patient is diagnosed with HIT, vitamin K should be administered. (2, C)
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In patients with confi rmed HIT, we recommend that that the VKA be overlapped with a nonheparin anticoagulant for a minimum of 5 days and until the INR is within the target range over shorter periods of overlap and that the INR be rechecked after the anticoagulant effect of the nonheparin anticoagulant has resolved. (1, C)
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Management of Isolated HIT (HIT Without Thrombosis)

In patients with isolated HIT (HIT without thrombosis), we recommend the use of lepirudin or argatroban or danaparoid over the further use of heparin or LMWH or initiation/continuation of a VKA. (1, C)
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In patients with isolated HIT (HIT without thrombosis) who have normal renal function, we suggest the use of argatroban or lepirudin or danaparoid over other nonheparin anticoagulants. (2, C)
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Management of Patients With Acute HIT or Subacute HIT in Special Situations

In patients with acute HIT (thrombocytopenic, HIT antibody positive) or subacute HIT (platelets recovered, but still HIT antibody positive) who require urgent cardiac surgery, we suggest the use of bivalirudin over other nonheparin anticoagulants and over heparin plus antiplatelet agents. (2, C)
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In patients with acute HIT who require nonurgent cardiac surgery, we recommend delaying the surgery (if possible) until HIT has resolved and HIT antibodies are negative. (2, C)
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In patients with acute HIT or subacute HIT who require PCI, we suggest the use of
  • bivalirudin
(2, B)
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  • or argatroban
(2, C)
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over other nonheparin anticoagulants.
In patients with acute or subacute HIT who require renal replacement therapy, we suggest the use of argatroban or danaparoid over other nonheparin anticoagulants. (2, C)
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In patients with a past history of HIT who require ongoing renal replacement therapy or catheter locking, we suggest the use of regional citrate over the use of heparin or LMWH. (2, C)
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  • In pregnant patients with acute or subacute HIT, we suggest danaparoid over other nonheparin anticoagulants.
(2, C)
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  • We suggest the use of lepirudin or fondaparinux only if danaparoid is not available.
(2, C)
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Management of Patients With a Past History of HIT

In patients with a history of HIT in whom heparin antibodies have been shown to be absent who require cardiac surgery, we suggest the use of heparin (short-term use only) over nonheparin anticoagulants. (2, C)
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In patients with a history of HIT in whom heparin antibodies are still present who require cardiac surgery, we suggest the use of nonheparin anticoagulants over heparin or LMWH. (2, C)
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In patients with a history of HIT who require cardiac catheterization or PCI, we suggest the use of
  • bivalirudin
(2, B)
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  • or argatroban
(2, C)
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over other nonheparin anticoagulants.

In patients with a past history of HIT who have acute thrombosis (not related to HIT) and normal renal function, we suggest the use of fondaparinux at full therapeutic doses until transition to VKA can be achieved. (2, C)
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Recommendation Grading

Disclaimer

Overview

Title

Treatment And Prevention Of Heparin-Induced Thrombocytopenia

Authoring Organization

Publication Month/Year

February 1, 2012

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Heparin-induced thrombocytopenia (HIT) is an antibody-mediated adverse drug reaction that can lead to devastating thromboembolic complications, including pulmonary embolism, ischemic limb necrosis necessitating limb amputation, acute myocardial infarction, and stroke.
The guideline is providing treatment and prevention of HIT.

Target Patient Population

Patients receiving heparin

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Long term care, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism, D006493 - Heparin, D006495 - Heparin, Low-Molecular-Weight, D020521 - Stroke, D011655 - Pulmonary Embolism, D056824 - Upper Extremity Deep Vein Thrombosis, D006494 - Heparin Antagonists, D009203 - Myocardial Infarction

Keywords

thromboembolism, stroke, thrombocytopenia, limb ischemia, myocardial infarction (MI), deep vein thrombosis, heparin, adverse drug reaction

Source Citation

DOI: https://doi.org/10.1378/chest.11-2303

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
182
Literature Search Start Date
January 1, 1976
Literature Search End Date
June 1, 2010