Evaluation of a Standardized Protocol Using Lepirudin or Argatroban for Heparin-Induced Thrombocytopenia

Kenneth      Kennedy; Doug      Steinke; Shawn      King; Kevin      Poe; Jordan      Reeves; Marintha      Short

Abstract

Study Objective: To evaluate the effectiveness of our institutions heparin-induced thrombocytopenia (HIT) protocol in achieving a therapeutic activated partial thromboplastin time (aPTT) and to evaluate patient outcomes related to bleeding and thrombotic events before and after protocol implementation. Design: Retrospective, single-center, pre- and post- assessment of a protocol previously approved at our institution. Setting: 400-bed community hospital serving surrounding rural populations with emphasis in cardiothoracic surgery. Patients: Retrospective chart review based on drug charge data identified 29 patients that received either argatroban or lepirudin for greater than 24 hours. Nineteen patients received either argatroban or lepirudin prior to HIT-protocol implementation, while the remaining ten received either drug after the HIT protocol was implemented. Intervention: Implementation of HIT protocol occurred in March 2009. Patients were divided into pre-protocol and post-protocol groups. Results: Primary outcome was to evaluate the number of therapeutic, subtherapeutic, and supratherapeutic aPTTs between two groups. In the pre-protocol group, aPTTs were therapeutic, subtherapeutic, and supratherapeutic 48.5% (164/338), 14.2% (48/338), and 37.2% (126/338) of the time, respectively. Meanwhile aPTTs in the post-protocol group were therapeutic, subtherapeutic, and supratherapeutic 46.6% (89/191), 22% (42/191), and 31.4% (60/191) of the time, respectively. The number of subtherapeutic aPTTs was statistically higher in the post-protocol group compared to the pre-protocol group. Secondary endpoints included the number of bleeding events and number of thrombotic events. None of the secondary endpoints reached statistical significance. Time to therapeutic aPTT was also evaluated: in the pre-protocol group median time (range) was 15 hours (2-108.6) compared to 8.1 hours (2.3-94.2) in the post-protocol group. Conclusions: Adoption and implementation of HIT protocol at our institution resulted in significantly more subtherapeutic aPTTs as compared to time prior to protocol. Although not statistically significant, the time required to obtain therapeutic aPTT was reduced by almost 50% after protocol implementation, which could be of clinical importance. Larger studies are needed to continue to assess if standardized protocols are effective in treatment of HIT.

Keywords: Argatroban, heparin-induced thrombocytopenia, HIT, lepirudin, protocol, standardized, treatment, pre, post, activated partial thromboplastin time, aPTT