Non-heparin anticoagulants for treatment of acute HIT
| Drug . | Mechanism of action . | Route of administration . | Primary mechanism of elimination (half-life) . | Dosing . | Laboratory monitoring . |
|---|---|---|---|---|---|
| Argatroban | Direct thrombin inhibitor | IV | Hepatobiliary (40-50 min) | Bolus: none | Adjust to APTT 1.5-3.0 times baseline |
| Continuous infusion: | |||||
| Normal organ function → 2 μg/kg/min | |||||
| Liver dysfunction (bilirubin >1.5 mg/dL) → 0.5-1.2 μg/kg/min | |||||
| Heart failure, anasarca, postcardiac surgery → 0.5-1.2 μg/kg/min | |||||
| Bivalirudin* | Direct thrombin inhibitor | IV | Enzymatic (25 min) | Bolus: none | Adjust to APTT 1.5-2.5 times baseline |
| Continuous infusion: | |||||
| Normal organ function → 0.15 mg/kg/h | |||||
| Renal or liver dysfunction → dose reduction may be appropriate | |||||
| Danaparoid | Indirect factor Xa inhibitor | IV | Renal (24 h) | Bolus: | Adjust to danaparoid-specific anti-Xa activity of 0.5-0.8 units/mL |
| <60 kg, 1500 units | |||||
| 60-75 kg, 2250 units | |||||
| 75-90 kg, 3000 units | |||||
| >90 kg, 3750 units | |||||
| Accelerated initial infusion: | |||||
| 400 units/h × 4 h, then 300 units/h × 4 h | |||||
| Maintenance infusion: | |||||
| Normal renal function → 200 units/h | |||||
| Renal dysfunction → 150 units/h | |||||
| Fondaparinux* | Indirect factor Xa inhibitor | SC | Renal (17-24 h) | <50 kg → 5 mg once per day | None |
| 50-100 kg → 7.5 mg once per day | |||||
| >100 kg → 10 mg once per day | |||||
| Apixaban*† | Direct factor Xa inhibitor | PO | Hepatic (8-15 h) | HITT: | None |
| 10 mg twice per day × 1 week, then 5 mg twice per day | |||||
| Isolated HIT: | |||||
| 5 mg twice per day until platelet count recovery | |||||
| Dabigatran*† | Direct thrombin inhibitor | PO | Renal (12-17 h) | HITT: | None |
| 150 mg twice per day after ≥5 days of treatment with a parenteral non-heparin anticoagulant | |||||
| Isolated HIT: | |||||
| 150 mg twice per day until platelet count recovery | |||||
| Rivaroxaban*† | Direct factor Xa inhibitor | PO | Renal (5-9 h) | HITT: | None |
| 15 mg twice per day × 3 weeks, then 20 mg once per day | |||||
| Isolated HIT: | |||||
| 15 mg twice per day until platelet count recovery |
| Drug . | Mechanism of action . | Route of administration . | Primary mechanism of elimination (half-life) . | Dosing . | Laboratory monitoring . |
|---|---|---|---|---|---|
| Argatroban | Direct thrombin inhibitor | IV | Hepatobiliary (40-50 min) | Bolus: none | Adjust to APTT 1.5-3.0 times baseline |
| Continuous infusion: | |||||
| Normal organ function → 2 μg/kg/min | |||||
| Liver dysfunction (bilirubin >1.5 mg/dL) → 0.5-1.2 μg/kg/min | |||||
| Heart failure, anasarca, postcardiac surgery → 0.5-1.2 μg/kg/min | |||||
| Bivalirudin* | Direct thrombin inhibitor | IV | Enzymatic (25 min) | Bolus: none | Adjust to APTT 1.5-2.5 times baseline |
| Continuous infusion: | |||||
| Normal organ function → 0.15 mg/kg/h | |||||
| Renal or liver dysfunction → dose reduction may be appropriate | |||||
| Danaparoid | Indirect factor Xa inhibitor | IV | Renal (24 h) | Bolus: | Adjust to danaparoid-specific anti-Xa activity of 0.5-0.8 units/mL |
| <60 kg, 1500 units | |||||
| 60-75 kg, 2250 units | |||||
| 75-90 kg, 3000 units | |||||
| >90 kg, 3750 units | |||||
| Accelerated initial infusion: | |||||
| 400 units/h × 4 h, then 300 units/h × 4 h | |||||
| Maintenance infusion: | |||||
| Normal renal function → 200 units/h | |||||
| Renal dysfunction → 150 units/h | |||||
| Fondaparinux* | Indirect factor Xa inhibitor | SC | Renal (17-24 h) | <50 kg → 5 mg once per day | None |
| 50-100 kg → 7.5 mg once per day | |||||
| >100 kg → 10 mg once per day | |||||
| Apixaban*† | Direct factor Xa inhibitor | PO | Hepatic (8-15 h) | HITT: | None |
| 10 mg twice per day × 1 week, then 5 mg twice per day | |||||
| Isolated HIT: | |||||
| 5 mg twice per day until platelet count recovery | |||||
| Dabigatran*† | Direct thrombin inhibitor | PO | Renal (12-17 h) | HITT: | None |
| 150 mg twice per day after ≥5 days of treatment with a parenteral non-heparin anticoagulant | |||||
| Isolated HIT: | |||||
| 150 mg twice per day until platelet count recovery | |||||
| Rivaroxaban*† | Direct factor Xa inhibitor | PO | Renal (5-9 h) | HITT: | None |
| 15 mg twice per day × 3 weeks, then 20 mg once per day | |||||
| Isolated HIT: | |||||
| 15 mg twice per day until platelet count recovery |
Guidance on selecting an anticoagulant for an individual patient is provided in the remarks associated with recommendation 3.1.
APTT, activated partial thromboplastin time; IV, intravenous; PO, per os; SC, subcutaneous.
Not approved for treatment of acute HIT.
Dosing for treatment of acute HIT is not well established. Suggested dosing is extrapolated from venous thromboembolism and based on limited published experience in HIT.