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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Anticoagulant selection in heparin-induced thrombocytopenia (HIT; suspected or confirmed)

Anticoagulant selection in heparin-induced thrombocytopenia (HIT; suspected or confirmed)
Anticoagulant Features affecting selection Mechanism, administration, and monitoring
Argatroban
  • Short-acting
  • Can be used in CKD; no dose adjustment needed
  • Eliminated hepatically; dose adjustment needed in liver impairment
  • Can be used in pregnancy
  • Use in breastfeeding unknown
  • Parenteral direct thrombin inhibitor
  • Administered by continuous intravenous infusion
  • Monitored and adjusted by aPTT; obtain aPTT prior to initiation, two hours after starting infusion, and after dose changes
  • Half-life approximately 40 to 50 minutes (prolonged to approximately 180 minutes in hepatic impairment)
  • Prolongs the PT/INR
  • No reversal agent (but effect is rapidly reversed upon discontinuation)
  • Expensive
Bivalirudin
  • Short-acting
  • Eliminated by the kidney; dose adjustment needed in CKD
  • Can be used in liver impairment; no dose adjustment is needed
  • Multi-organ failure in critical illness; dose adjustment is needed
  • Can be used in pregnancy
  • Use in breastfeeding unknown
  • Parenteral direct thrombin inhibitor
  • Administered by continuous intravenous infusion
  • Monitored and adjusted by aPTT; obtain aPTT prior to infusion, two hours after starting infusion, and after dose changes
  • Half-life approximately 25 minutes (prolonged to approximately 3.5 hours in ESKD)
  • Prolongs the PT/INR, less so than argatroban
  • No reversal agent (but effect is rapidly reversed upon discontinuation)
  • Expensive
Danaparoid (not available in United States)
  • Parenteral agent; may be given subcutaneously following initial intravenous bolus
  • Eliminated by the kidney; dose adjustment needed in CKD
  • Can be used in liver impairment; no dose adjustment is needed
  • Can be used in pregnancy
  • Can be used in breastfeeding
  • Parenteral inhibitor of thrombin and factor Xa (indirect, heparinoid, derived from porcine intestine)
  • Administered intravenously or subcutaneously (intravenous dosing preferred if an invasive procedure is likely to be needed)
  • No routine coagulation test monitoring; anti-factor Xa activity can be monitored if needed*
  • Half-life (anti-factor Xa activity) is approximately 25 hours; prolonged to 29 to 35 hours in CKD
  • No reversal agent
Fondaparinux
  • Subcutaneous agent
  • Eliminated by the kidney; dose adjustment is needed for CrCl 30 to 50 mL/minute and should not be used if CrCl is <30 mL/minute
  • Can be used in liver impairment; no dose adjustment is needed
  • Not suitable if likely to undergo urgent invasive procedure due to long half-life
  • Can be used in pregnancy
  • Parenteral inhibitor of factor Xa (indirect)
  • Administered subcutaneously, once per day
  • No routine coagulation test monitoring; anti-factor Xa activity can be monitored if needed*
  • Half-life 17 to 21 hours; prolonged in renal impairment, older adults, and low body weight
  • Possible reversal with andexanet alfa
Apixaban
  • Oral agent
  • Eliminated by the kidney and liver (less dependent on kidney function than other DOACs); no dose adjustment is needed for CrCl ≥25 mL/minute or mild to moderate hepatic impairment
  • Do not use if CrCl <25 mL/minute, serum creatinine >2.5 mg/dL, dialysis-dependent, or severe hepatic impairment
  • Subject to CYP3A4 and P-gp drug interactions
  • Use in pregnancy and breastfeeding unknown
  • Oral direct factor Xa inhibitor
  • Administered orally, twice-daily dosing (higher initial dose for VTE treatment)
  • Half-life approximately 12 hours
  • No routine coagulation test monitoring; anti-factor Xa activity can be monitored if needed*
  • Reversal agent (andexanet alfa or PCC)
  • Not dialyzable
Dabigatran
  • Oral agent
  • Mostly eliminated by the kidney; no dose adjustment needed for CrCl >30 mL/minute or liver impairment
  • Do not use if CrCl ≤30 mL/minute or dialysis-dependent
  • Subject to P-gp drug interactions
  • Use in pregnancy and breastfeeding unknown
  • Oral direct thrombin inhibitor
  • Administered orally, twice-daily dosing (initial parenteral agent for VTE treatment)
  • Half-life 12 to 17 hours; prolonged up to 28 hours in severe renal impairment
  • No routine coagulation test monitoring; refer to UpToDate for monitoring in selected cases
  • Reversal agent (idarucizumab)
Edoxaban
  • Oral agent
  • Eliminated by the kidney and liver; no dose adjustment required for CrCl >50 mL/minute or mild liver impairment
  • Dose adjustment is needed for CrCl 15 to 50 mL/minute
  • Do not use if CrCl ≤15 mL/minute or >95 mL/minute, dialysis-dependent, or moderate to severe liver impairment
  • Dose adjustment needed for body weight ≤60 kg
  • Subject to CYP3A4 and P-gp drug interactions
  • Use in pregnancy and breastfeeding unknown
  • Oral direct factor Xa inhibitor
  • Administered orally, once-daily dosing (initial parenteral agent for VTE treatment)
  • Half-life 10 to 14 hours; prolonged in renal impairment
  • No routine coagulation test monitoring; anti-factor Xa activity can be monitored if needed*
  • Reversal agent (andexanet alfa or PCC)
Rivaroxaban
  • Eliminated by the kidney and liver; no dose adjustment is needed for CrCl >30 mL/minute or mild liver impairment
  • Do not use if CrCl ≤30 mL/minute, dialysis-dependent, or moderate to severe hepatic impairment
  • Subject to CYP3A4 and P-gp drug interactions
  • Use in pregnancy and breastfeeding unknown
  • Oral direct factor Xa inhibitor
  • Administered orally once-daily dosing (initial twice-daily dosing for VTE treatment)
  • Half-life 5 to 9 hours
  • No routine monitoring; anti-factor Xa activity can be monitored if needed*
  • Reversal agent (andexanet alfa or PCC)
Warfarin
  • Cannot be used until stable anticoagulation with another non-heparin anticoagulant has been established and the platelet count has normalized or returned to baseline
  • Can be used in severe kidney or liver impairment; monitor INR closely
  • Many drug and dietary interactions
  • Can be used in patients with a mechanical heart valve
  • Teratogen: Avoid in first trimester of pregnancy unless benefits outweigh risks (eg, mechanical heart valve)
  • Oral vitamin K antagonist, interferes with synthesis of thrombin and factors VII, IX, and X
  • Administered orally, once-daily dosing with regular monitoring and dose adjustments based on the PT/INR
  • Requires at least five consecutive days of overlapping non-heparin anticoagulant that is continued until the INR is therapeutic
  • If transitioning from argatroban to warfarin, refer to institutional guidelines for INR target as both agents elevate the INR
  • Reversal agent (vitamin K and PCC)
  • Inexpensive

Refer to UpToDate for details of the clinical evaluation for HIT, duration of non-heparin anticoagulant therapy, and other considerations. For patients with a thromboembolic event, DOACs require initial higher dosing or a parenteral agent:

  • Dabigatran or edoxaban – Must be preceded by five days of a parenteral anticoagulant.
  • Apixaban or rivaroxaban – Initial dosing is higher.

For agents that inhibit factor Xa, anti-factor Xa testing may be useful in selected patients (prior to urgent neurosurgery, extremes of body weight, CKD). If anti-factor Xa testing is used, it must be calibrated for the specific anticoagulant. Anti-factor-Xa activity calibrated for fondaparinux or danaparoid is not available in many clinical settings.

HIT: heparin-induced thrombocytopenia; CKD: chronic kidney disease; aPTT: activated partial thromboplastin time; PT: prothrombin time; INR: international normalized ratio; ESKD: end-stage kidney disease; factor Xa: activated factor X; DOACs: direct-acting oral anticoagulants; CrCl: creatinine clearance; VTE: venous thromboembolism; PCC: prothrombin complex concentrate.

* If anti-factor Xa monitoring is used, it must be done using an assay calibrated for the specific drug the patient is taking.

¶ In some countries other than the United States, the approved product information recommends a dose reduction in patients with moderately impaired kidney function and elevated risk of bleeding.
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