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Evaluation of a multi‐target direct thrombin inhibitor dosing and titration guideline for patients with suspected heparin‐induced thrombocytopenia
Author(s) -
Gilmore James F.,
Adams Christopher D.,
Blum Rachel M.,
Fanikos John,
Anne Hirning Beth,
Matta Lina
Publication year - 2015
Publication title -
american journal of hematology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.456
H-Index - 105
eISSN - 1096-8652
pISSN - 0361-8609
DOI - 10.1002/ajh.24042
Subject(s) - dosing , medicine , bivalirudin , argatroban , direct thrombin inhibitor , partial thromboplastin time , guideline , heparin , intensive care medicine , heparinoid , anesthesia , pharmacology , surgery , dabigatran , warfarin , coagulation , thrombin , percutaneous coronary intervention , atrial fibrillation , platelet , pathology , myocardial infarction
To the Editor: Heparin-induced thrombocytopenia (HIT) is an antibody-mediated adverse drug reaction that can occur in patients receiving heparinoid therapy [1,2]. Management of HIT consists of discontinuation of the heparinoid and anticoagulation using a direct thrombin inhibitor (DTI), such as argatroban and bivalirudin. Institutions have implemented dosing guidelines for initial DTI dosing and titration. Standardization of DTI dosing and titration using a nursing driven guideline titrating to an activated partial thromboplastin time (aPTT) goal of 50–80 has been shown to reduce time and number of titrations to therapeutic aPTT [3]. An analysis of two dosing guidelines for argatroban achieved an aPTT goal of 50–70 [4]. To our knowledge, currently no published bivalirudin dosing guideline exists that allows for a more stringent aPTT goal. Brigham and Women’s Hospital instituted a dosing and titration guideline for argatroban and bivalirudin that allowed the prescriber to select between three therapeutic aPTT goals: 50–80, 50–70, or 60–80 (Table 1). The protocol provided guidance for agent selection and dosing strategy based on age, organ function, and clinical condition. We hypothesized that a standardized dosing and titration guideline for DTIs improve achievement of therapeutic goals in patients with proven or suspected HIT. We conducted a single center, prospective, observational evaluation of patients treated with a DTI according to a dosing and titration guideline compared to a historic control