ABSTRACT
Although the prevalence of heparin-induced thrombocytopenia (HIT) has decreased these last years in France with the widespread use of low molecular weight heparins, HIT remains an important severe prothrombotic disease that needs to be diagnosed and treated adequately. HIT is caused by IgG antibodies that bind to modified platelet factor 4 and induce platelet and monocyte activation with increased thrombin generation. Venous and arterial thromboses are therefore frequent in HIT, explaining why substituting heparin with a potent alternative anticoagulant such as danaparoid sodium, lepirudin, or argatroban is necessary in every affected patient. However, the management of these drugs is difficult, and the diagnosis of HIT always has to be assessed on both clinical criteria and laboratory tests that detect heparin-dependent antibodies in the patient's blood (antigen assays and platelet activation tests). When the clinical probability of HIT is high, the first requirement is to discontinue heparin, without waiting for the results of laboratory assays. The choice of the alternative anticoagulant is then driven by several criteria. Danaparoid (mainly anti-Xa) is often preferred in cases of isolated thrombocytopenia, and lepirudin (anti-IIa) is preferred when surgery is required due to its shorter half-life. But with these two drugs the risk of overdosage is high in patients with renal failure. Argatroban (anti-IIa) is thus a useful drug in critically ill patients because of its hepatobiliary excretion. Unfortunately, argatroban is not available in many European countries including France.
KEYWORDS
Heparin - thrombocytopenia - argatroban - lepirudin - danaparoid
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Yves GruelM.D.
Service d'Hématologie-Hémostase, Hôpital Trousseau, CHU of Tours
37044 Tours Cedex, France
eMail: gruel@med.univ-tours.fr
