darkhorse
Forum Elite
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You are asked to consult on a 34-year-old male with thrombocytopenia. He sustained a motor
vehicle collision 10 days ago, resulting in shock, internal bleeding, and acute renal failure. An
exploratory laparotomy was performed that showed a ruptured spleen requiring a splenectomy.
He also underwent an open reduction and internal fixation of the left femur. The platelet count
was 260,000 cells/L on admission. Today it is 68,000 cells/L. His medications are oxacillin,
morphine, and subcutaneous heparin. On examination the vital signs are stable. The
examination is significant for an abdominal scar that is clean and healing. The patient's left leg
is in a large cast and is elevated. The right leg is swollen from the calf downward. Ultrasound of
the right leg shows a deep venous thrombosis. Antiheparin antibodies are positive. Creatinine is
3.2 mg/dL. What is the most appropriate next management step?
A. Discontinue heparin.
B. Stop heparin and start enoxaparin.
C. Stop heparin and start argatroban.
D. Stop heparin and start lepirudin.
E. Observe the patient.
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| dr.wad
Forum Senior
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D
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| me007
Forum Guru
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Lepirudin - for use in pts with thrombosis related to heparin-induced thrombocytopenia. Accumulates in renal insufficiency, no antidote exist.
Argatroban - for use in pts with HIT with or without thrombosis. Its clearance is not affected by renal disease but is dependent on liver function.
Probably C bcs of creatinine level.
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| chemamr
Moderator and PGY1
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C might be a good option
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| drdg
Forum Senior
Topics: 31
Posts: 176
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C.
Both lepirudin and argatroban can be used for prophylaxis or treatment of thrombosis in patients with heparin-induced thrombocytopenia. However, argatroban is is metabolized in the liver and , it may be used in patients with renal dysfunction.
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| cool doctor
Forum Junior
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great question
thanks guys I didnt know the difference between C,D
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| darkhorse
Forum Elite
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well done guys!
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| darkhorse
Forum Elite
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C
Heparin-induced thrombocytopenia (HIT) is common in patients who receive heparin products.
Because the risk of death is significantly increased in patients with HIT type II and thrombosis
if no anticoagulation is given, observation or simply discontinuation of heparin is not an option.
Although enoxaparin and other low-molecular-weight heparins have less of a propensity to
cause HIT, they are cross-reactive in patients who already have HIT and thus are
contraindicated. Direct thrombin inhibitors are the treatment of choice. Lepirudin is a
recombinant direct thrombin inhibitor. It may be given intravenously or subcutaneously. It is
excreted throught the kidney and lacks an antidote. Therefore, it is relatively contraindicated in
patients with renal insufficiency. Argatroban is another direct thrombin inhibitor. Because it is
hepatically metabolized, it is a reasonable option in patients with HIT and renal insufficiency.
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