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SUSAN FUGATE, PHARM.D., CaCP, BCPS, is Clinical Pharmacy Specialist, Integris Health Anticoagulation Clinics, and Associate Professor, Department of Pharmacy, Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma, Oklahoma City. JULIA CHIAPPE, PHARM.D., is Clinical Pharmacy Specialist in Drug Information, Integris Baptist Medical Center, Oklahoma City.

Address correspondence to Dr. Fugate at the Department of Pharmacy, Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma, 1110 North Stonewall, P.O. Box 26901, Oklahoma City, OK 73126 (Susan-Fugate{at}ouhsc.edu).

Purpose. An evidence-based heparin- induced thrombocytopenia (HIT) treatment protocol to standardize the management of confirmed or suspected HIT was developed. Summary. In a retrospective review of 10 patients with known or suspected HIT over a two-year period, medical records were evaluated for baseline laboratory results, treatment selection, initial dosing and monitoring, discontinuation of heparin, and alternative therapies chosen. Six of 10 patients had antibody-confirmed HIT at admission. Nine patients received alternative anticoagulation therapy with one of two formulary direct thrombin inhibitor (DTI) agents, lepirudin and argatroban; 1 patient was given fondaparinux. Medical record analyses revealed deficiencies in both initial and transitional dose administration and renal function monitoring, order omissions, infusion-related medication errors, and treatments that were unsubstantiated, inappropriate, or lacking in regulatory approval. The new treatment protocol developed to assist physicians, pharmacists, and nurses with HIT management focused primarily on the two agents labeled for HIT, lepirudin and argatroban. The protocol established baseline levels for the selection of anticoagulation therapy as well as guidance in DTI selection, use, and monitoring. Guidelines for initial dosing and continuous infusion rates based on weight and detailed instructions in all aspects of therapy discontinuation (transition) were included. HIT treatments unsupported by data ensuring the efficacy and safety of therapies were excluded. Careful review of the relevant literature led to the inclusion of alternative anticoagulant treatments based on issues of safety, efficacy, cost, and convenience of dose forms. Conclusion. A treatment protocol for HIT was developed and implemented in a tertiary care hospital in an effort to improve the management of patients suffering from this complication. Index terms: Anticoagulants; Argatroban; Dosage; Errors, medication; Fondaparinux; Heparin; Lepirudin; Protocols; Rational therapy; Thrombocytopenia; Toxicity